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SYPHILIS  AND  PUBLIC 
HEALTH 


BY 

EDWARD  B.  VEDDER,  A.M.,  M.D. 

LIEUTENANT-COLONEL,    MEDICAL    COEPS,    UNITED    STATES    ARMY 


PUBLISHED  BY  PERMISSION  OF  THE  SURGEON-GENERAL 
UNITED  STATES  ARMY 


LEA   &   FEBIGER 

PHILADELPHIA  AND  NEW  YORK 
1918 


Copyright 

LEA   &   FEBIGER 

1918 


CONTENTS. 


INTRODUCTION. 

1.  Importance  of  Syphilis  in  Relation  to  Public  Health     ...        17 

1.  Statistics  Indicating  the  Extent  of  the  MortaUty  Due  to 

Syphihs 18 

2.  Syphihs  a  Sanitary  Problem  of  First  Importance  because 

it  is  Very  Prevalent,  Very  Fatal  and  UncontroUed        .       23 

2.  General  Plan  of  the  Work 24 

References 25 


CHAPTER  I. 

The  Prevalence  of  Syphilis. 

1.  The  Incidence  Varies  in  Different  Groups  of  the  Population    .  27 

2.  Statistics  from  Other  Coimtries 29 

1.  Russia 29 

2.  Serbia 31 

3.  Asia  Minor 31 

4.  The  Tropics 32 

5.  Africa 34 

6.  Germany 35 

7.  Budapest 38 

8.  Belgium 38 

9.  France 38 

10.  Austraha 40 

11.  England 41 

12.  Canada 46 

3.  Statistics  from  Different  Groups  in  the  United  States   ...  46 

1.  Prostitutes 47 

2.  Insane 49 

3.  Percentages  of  Syphihs  among  Patients  in  Hospitals  and 

Dispensaries 53 

4.  Tuberculous  Patients 68 

5.  Criminals 70 


IV  CONTENTS 

Statistics  from  Different  Groups  in  the  United  States — 

6.  Sick  Children 72 

7.  Individuals  that  are  Presumably  Healthy 76 

8.  Candidates  for  a  Commission  in  the  Army       ....  82 

9.  Presumably  Healthy  Female  Adults 83 

10.  Relative  Prevalence  of  SyphiUs  among  Negroes     ...  85 

4.  Summary  of  Results  of  the  Investigation 96 

References 102 

CHAPTER  II. 

The  Sources  of  Infection  and  Methods  of  Transmission. 

I.  The  Sources  of  Infection 110 

A.  Immediate  Bodily  Contact Ill 

1.  The  Primary  Lesion  or  Chancre Ill 

2.  The  Secondary  Lesions 112 

3.  The  Tertiary  Lesions 114 

B.  Mediate  Infection 116 

1.  Infectiousness  of  Various  Bodily  Fluids  .      .      .      .  116 

Blood 116 

Milk 117 

Sputum,  Sweat  and  Urine 118 

SaUva 119 

Spinal  Fluid 119 

Spermatic  Fluid 120 

2.  ViabiUty  of  the  Treponema  Pallidum  Outside  the 

Body 120 

C.  Methods  by  which  the  Treponema  PalUdum  Gains  Access 

to  the  Body 124 

1.  Penetrative  Power  of  the  Treponema  Pallidum        .  124 

2.  Genitotropic  Tendency  of  the  Treponema  Palhdum  127 

3.  Syphihs  "d'Emblee" 128 

II.  Methods  of  Transmission 135 

A.  Syphilis  Insontium 135 

1.  Marital  Syphilis 135 

1.  Transmission  from  Wife  to  Husband  .      .      .  136 

2.  Transmission  from  Husband  to  Wife  .      .      .  136 

3.  Methods  of  Transmission 137 

The  Delayed  Chancre 137 

Secondary  Lesions  that  Escape  Notice    .  138 

By  Conception 140 

Accidental  Extragenital  Infection  of  the 

Wife 142 


CONTENTS  V 

Methods  of  Transmission — SyphUis  Insontium — • 

2.  Hereditary  Syphilis 142 

1.  Methods  of  Transmission 142 

2.  Results  of  Hereditary  Syphilis        .      .      .      .  142 

3.  Comparative   Frequency   of   the   Results   of 

Hereditary  SyphiUs 144 

4.  CoUe's  and  Profeta's  So-called  Laws    .      .      .  146 

3.  SyphiUs  Sine  Coitu  (Extragenital  Chancres)     .      .  147 

1.  Frequency 148 

2.  Methods  of  Transmission 150 

B.  SyphiUs  Pravorum 157 

1.  The  Percentage  of  SyphiUtic   Infections  Due  to 

Prostitution 157 

References 159 


CHAPTER  III. 

Personal  Prophylaxis. 

I.  Methods  that  May  Be  Taken  by  the  Individual  to  Prevent 

Genital  Infection 162 

1.  The  Surgical  Method:  Circumcision 163 

2.  Mechanical  Method 166 

3.  Chemical  Methods  of  Prevention 167 

1.  The  Status  of  Such  Methods  Prior  to  the  Experi- 

ments of  Metchnikoff 169 

2.  Practical  Results  Obtained  from  the  AppUcation  of 

Prophylaxis ISO 

4.  The  Ethics  of  Venereal  Prophylaxis 192 

II.  Methods  that  May  Be  Taken  by  the  Individual  to  Prevent 

Extragenital  Infection 197 

1.  Kissing 198 

2.  Instruments  Used  in  Various  Trades 198 

3.  Smokers'  Articles 198 

4.  Drinking  Glasses 198 

5.  Minor  Operations 199 

6.  Circumcision 200 

7.  Tattooing 200 

8.  Physicians,  Nurses  and  Those  in  Attendance  on  the  Sick  200 

9.  Wet-nurses 201 


VI  CONTENTS 

III.  Syphilis  and  Marriage 202 

1.  Impracticability  of  Regulating  Marriage  of  Syphilitics 

by  Law 202 

2.  The  Physician's  Responsibihty 203 

1.  Rules  Advocated  by  Various  Authorities  for  the 

Marriage  of  SyphiUtics 205 

3.  The  Standard  of  Cure 209 

4.  Wassermann-fast  Cases 209 

References 209 


CHAPTER  IV. 

Public  Health  Measures, 

A.  Prostitution  as  a  Sociological  Problem      .  ~ 212 

1.  The  Cause  of  Prostitution 213 

2.  Sociological  Reform 214 

3.  Education 217 

B.  The  Control  of  Venereal  Diseases 219 

I.  Those  Due  to  Prostitution 219 

1.  Laissez-faire 220 

2.  Suppression  of  Prostitution 221 

3.  Segregation  and  Reglementation 224 

4.  Systematic  Treatment  of  Those  Infected      .      .      .  235 

1.  Notification 236 

2.  Quacks  and  Quack  Remedies 242 

3.  PubHcity 247 

4.  Provision  of  Adequate  Facilities  for  Treatment  249 

For  the  General  Public 255 

For  Prostitutes 256 

A  Supply  of  Salvarsan  at  a  Reasonable  Cost  259 
II.  PubUc  Health  Measures  for  the  Prevention  of  Syphilis 

Insontium 261 

1.  Barbershops 261 

2.  Soda  Fountains 262 

3.  Minor  Operations 262 

References 264 


CONTENTS  vii 


APPENDIX. 

Technic  of  Wassermann 265 

1.  Cell  Suspension 265 

2.  Complement 265 

3.  Amboceptor 265 

4.  Antigen 265 

5.  Titration  of  Complement 266 

6.  Titration  of  Amboceptor 266 

7.  Titration  of  Antigen 267 

8.  Tests  of  Antigenic  Power 267 

9.  Anticomplementary  Test 268 

10.  Performance  of  the  Test 268 

Law  of  the  State  of  Missouri  for  the  Regulation  of  the  Practice  of 

Medicine  and  Surgery 270 

The  Control  of  SyphiHs  in  the  Army 280 

Methods  Employed  by  Some  Cities 292 

Index  of  Authors 303 

Subject  Index 307 


SYPHILIS  AND  PUBLIC  HEALTH. 


INTRODUCTION. 

The  importance  of  this  subject  cannot  be  too  highly 
emphasized.  SyphiHs  is  one  of  the  most  prevalent  of  all 
infectious  diseases,  causes  an  incalculable  amount  of  suffering 
and  economic  loss,  and  because  it  has  so  far  eluded  sanitary 
control  is  a  constant  menace  not  only  to  the  licentious  but 
to  the  clean-living  public  as  well. 

Because  of  the  secrecy  which  has  always  shrouded  the 
disease  we  do  not  know  and  perhaps  never  shall  know  the 
exact  incidence  of  syphilis,  but  sufficient  is  known  with  regard 
to  its  prevalence  to  justify  the  above  statement.  For  several 
years  past  syphilis  has  been  made  a  reportable  disease  by 
the  city  of  New  York.  During  the  fourteen  weeks  from  July 
4  to  October  3,  1914,  25,633  infectious  and  contagious  dis- 
eases were  reported.  Of  these,  syphilis  stood  first  on  the  list, 
with  6432  cases,  or  28  per  cent.;  tuberculosis  second,  with 
5525  cases,  or  21  per  cent.;  diphtheria  third,  with  3370  cases, 
or  13  per  cent.;  measles  fourth,  with  2750  cases,  or  11  per 
cent.;  scarlet  fever  fifth,  with  1064  cases,  or  4  per  cent. 
From  this  and  many  other  statistics  which  will  be  quoted 
later  it  would  appear  that  with  the  exception  of  gonorrhea 
syphilis  is  the  most  prevalent  of  all  serious  infectious  diseases. 

If  statistics  as  to  the  incidence  of  syphilis  are  somewhat 
vague,  figures  as  to  the  amount  of  morbidity  and  mortality 
caused  by  syphilis  are  still  more  vague.  Syphilis  appears 
seldom  in  death  certificates,  for  the  family  physician  always 
seeks  a  more  euphonious  title  to  cover  the  demise.  How- 
ever, if  it  be  remembered  that  syphilis  is  the  real  cause  of 
2 


18  SYPHILIS  AND  PUBLIC  HEALTH 

death  in  all  cases  of  paresis,  locomotor  ataxia  and  aortic 
aneurysm,  in  many  cases  of  cerebral  hemorrhage  and  apoplexy, 
organic  diseases  of  the  heart,  liver  and  kidneys,  and  that  it 
is  a  contributory  cause  of  death  in  a  host  of  other  condi- 
tions, including,  perhaps,  one-fifth  of  all  cases  of  pulmonary 
tuberculosis,  the  real  influence  of  syphilis  on  the  mortality 
rate  begins  to  be  suspected. 

Osier  some  time  ago  made  the  statement  that  "of  the 
killing  diseases,  syphilis  comes  third  or  fourth."  In  a  more 
recent  article^  Osier  analyzes  the  statistics  of  the  Registrar- 
General  for  1915  as  follows : 

Number  of 
Total.  syphilitics. 

Diseases  of  the  nervous  system    ....  58,000 

General  paralysis .  2,263  2,263 

Locomotor  ataxia 735  735 

Other  diseases  of  the  cord 2,846  1,500 

Cerebral  hemorrhage  (apoplexy)    .      .      .  25,423  3,000 

Softening  of  the  brain 1,472  500 

Paralyses  without  specified  cause        .      .  2,983  500 

Other  diseases  of  nervous  system        .      .  15,000  2,000 

Diseases  of  the  vascular  system: 

Aneurysm  and  aortitis 1,141  1,000 

Organic  disease  of  heart 56,000  5,000 

Diseases  of  arteries 10,000  3,000 

Total 19,498 

Including  stillbirths,  deaths  of  infants  under  one  month 
and  other  syphilitic  conditions.  Osier  estimated  that  the 
actual  deaths  from  syphilis  were  above  60,000,  a  number 
which  moves  syphilis  from  the  tenth  place  in  the  Registrar- 
General's  report  to  the  place  at  which  it  belongs,  at  the  top, 
an  easy  first  among  the  infections. 

Downing'  illustrates  this  fact  with  the  vital  statistics  for 
Massachusetts  for  1912.  According  to  the  records  the 
Treponema  pallidum  is  only  responsible  for  113  deaths;  but 
of  the  3188  stillbirths,  half  may  be  accredited  to  syphilis; 
231  died  of  general  paralj^sis  and  87  of  tabes.  One-half  of 
the  372  cases  called  paralysis  without  cause  may  be  accredited 
to  syphilis  and  nearly  all  of  the  56  recorded  as  softening  of  the 
brain.  One-tenth  of  the  3496  who  died  of  cerebral  hemor- 
rhage were  probably  syphilitic,  for  nearly  500  of  these  cases 


INTRODUCTION  19 

were  between  the  ages  of  twenty  and  fifty.  It  may  also  be 
estimated  that  one-tenth  of  the  1979  cases  under  the  heading 
of  diseases  of  the  arteries,  not  to  mention  some  of  the  4610 
organic  diseases  of  the  heart,  a  few  of  the  388  cirrhoses  and 
other  diseases  of  the  hver  and  a  few  of  the  478  suicides  may 
be  accredited  to  syphiHs.  In  round  numbers  and  counting 
the  stillbirths,  Downing  estimates  the  mortality  from  syphilis 
at  3000,  or  about  1  in  every  18  deaths,  making  its  record 
of  fatality  fall  behind  only  tuberculosis,  pneumonia  and 
cancer.  This  estimate  is  none  too  high.  Salmon  finds  that 
general  paralysis  in  New  York  State  stands  eighth  in  the 
mortality  tables  and  that  1  out  of  every  9  male  deaths 
between  forty  and  sixty  is  from  general  paralysis.  According 
to  Lenz,^  in  the  large  cities  25  per  cent,  of  syphilitics  die  as 
the  result  of  aortitis  (angina  pectoris,  aortic  insufficiency, 
aneurysm),  while  3  or  4  per  cent,  die  from  general  paralysis, 
1  or  2  per  cent,  from  tabes  and  at  least  10  per  cent,  more  as 
the  result  of  syphilitic  diseases  of  the  brain,  liver  and  kidneys. 
Almost  half  of  all  syphilitics  eventually  succumb  as  the  result 
of  their  infection.  Syphilis  is  therefore  the  greatest  cause  of 
death  of  men  in  the  large  cities. 

Brooks*  states  that  66  per  cent,  of  his  luetic  diseases  die 
from  or  with  serious  circulatory  diseases  apparently  of 
syphilitic  origin.  Stengel  and  Austin^  discuss  syphilis  as 
the  etiological  factor  in  certain  cases  of  nephritis.  Out  of 
84  cases  of  nephritis  there  were  66  in  which  possible  etiolog- 
ical factors  such  as  lead,  alcohol,  excessive  work,  exposure, 
senility,  etc.,  could  be  recognized.  But  in  18  cases  no  such 
factors  could  be  determined.  Of  these  18  cases  there  existed 
in  8  either  an  unquestionable  history  of  syphilis  or  a  positive 
Wassermann,  or  both.  In  6  of  the  remainder  no  Wassermann 
was  secured  while  in  only  4  was  syphilis  definitely  excluded. 
The  nephritis  occurring  in  early  secondary  syphilis  is  well 
known.  It  seems  probable  that  syphilis,  together  with 
mercurial  treatment,  may  be  responsible  for  a  considerable 
number  of  the  cases  of  nephritis  of  unknown  causation,  and 
that  here  again  the  influence  of  syphilis  on  the  death-rate 
must  be  taken  into  consideration.  An  estimate  of  the  annual 
mortality  caused  by  syphilis  in  Paris  is  given  in  the  following 


20 


SYPHILIS  AND  PUBLIC  HEALTH 


table  compiled,  by  Leredde/ 
for  the  year  1910. 


from  the  mortality  statistics 


Men. 

Syphilis 70 

Cancer  and  malignant  tumors  of 

the  buccal  cavity    ....        93 
Affections  of  the  nervous  system: 

General  paralysis        ....      133 

Ataxia 40 

Encephalitis 28 

Meningitis  (except  tuberculous)  439 
Paralysis  without  a  determined 

cause 240 

Diseases     of     the     spinal     cord 
(ataxia  excepted)    ....       49 

Epilepsy 31 

Cerebral  hemorrhage  (apoplexy)  1142 
Softening  of  the  brain  .  .  .  109 
Different  diseases  of  the  nervous 

system 39 

Diseases  of  the  circulatory  appa- 
ratus: 
Organic  maladies  of  the  heart    .    1526 

Angina  pectoris 87 

Arterial  disease,  aneurysm,  ath- 
eroma, etc 173 

Diseases  of  the  digestive  apparatus: 

Cirrhoses  of  the  liver       .      .      .     374 
Diseases  of  the  urinary  apparatus: 

Nephritis,  acute 26 

Bright's  disease 858 

Diseases  of  the  bones  (tuberculosis 

excepted) 26 

Sudden  death 139 


iVomen. 

Total. 

Syphilis. 

41 

Ill 

Ill 

13 

106 

80 

55 

188 

188 

26 

66 

66 

15 

43 

4 

350 

789 

78 

323 

563 

138 

52 

101 

33 

30 

61 

6 

1161 

2303 

768 

134 

243 

81 

37 


76 


25 


1807 

3333 

1111 

39 

126 

96 

72 

245 

122 

225 

629 

125 

22 

48 

4 

642 

1500 

300 

18 

44 

4 

107 

246 

24 
3364 

Further,  Leredde  estimates  that  syphilis  probably  kills 
25,000  persons  each  year  in  France. 

An  idea  as  to  the  amount  of  morbidity  and  mortality 
caused  by  syphilis  may  also  be  obtained  by  observing  known 
syphilitics  for  a  number  of  years.  This  has  been  done  by 
Mattauschek  ard  Pilcz,'  who  found  that  of  4134  officers  of 
the  Austrian  army  who  contracted  syphilis  between  the 
years  1800-1900,  on  January  1,   1912:' 

198  have  general  paralysis. 

113  have  locomotor  ataxia. 

132  have  cerebrospinal  syphilis. 


INTRODUCTION  21 

80  suffer  from  different  psychoses. 
17  died   of  aneurysm. 

147   died   of  tuberculosis. 
20  died  with  syphiHs  designated  as  the  cause. 

101  developed  myocarditis  and  arteriosclerosis  and  all  but 
15  died  from  this  condition. 

Thus  if  we  count  general  paralysis,  tabes,  cerebrospinal 
syphilis,  malignant  and  inveterate  syphilis,  aortic  aneurysm 
and  arteriosclerotic  conditions  which  are  undoubtedly 
dependent  on  syphilis  we  find  that  12  per  cent,  of  these 
luetics  died  as  the  direct  result  of  their  infection.  In  addi- 
tion there  are  2.64  per  cent,  who  apparently  die  as  the  result 
of  syphilis  if  we  count  the  cases  in  which  the  relation  between 
syphilis  and  the  arteriosclerosis  was  probable.  Finally,  if  we 
consider  the  large  number  of  cases  of  tuberculosis  that  are 
secondary  to  syphilis  we  are  then  able  to  consider  the  impor- 
tance of  syphihs  to  society.  The  actuaries  of  a  German  life 
insurance  company  estimate  that  the  mortality  of  luetics  is 
130  to  100  for  normal  individuals,  and  in  the  36-  to  50-year 
period  the  average  mortality  in  syphilitics  is  doubled. 

Finally,  we  have  the  life  insurance  statistics  compiled  in 
the  United  States.  Schroeder^  states-  that  the  Medico- 
Actuarial  Mortality  Invei  tigation  has  recently  completed  a 
study  of  the  experience  of  the  companies  represented,  the  ex- 
pected deaths  being  calculated  by  the  medico-actuarial  table 
based  on  standard  lives  during  the  years  1885-1908  inclusive. 
These  cases  are  divided  into  three  groups  and  only  include 
those  in  which  the  attack  occurred  at  least  three  years  prior 
to  the  date  of  the  application  except  group  three. 

SYPHILIS,  SURELY,  THOROUGHLY  TREATED,  TWO  YEARS' 

CONTINUOUS  TREATMENT  AND  ONE  YEAR  FREEDOM 

FROM  SYMPTOMS. 


Actual 
deaths. 

Expected 
deaths. 

Ratio  of  actual 

to  expected 

deaths, 

per  cent. 

13 

9.32 

139 

34 

19.56 

174 

Between  2  and  5  years  of  application 
Between  5  and  10  years  of  application 
More  than  10  years  prior  to  applica- 
tion          53  24.42  217 

100  53.30  188 


22 


SYPHILIS  AND  PUBLIC  HEALTH 


SYPHILIS,  SURELY,  NOT  THOROUGHLY  TREATED  OR  NO  DETAILS 
OF  TREATMENT   GIVEN. 


Actual 
deaths. 

Expected 
deaths. 

Ratio  of  actual 

to  expected 

deaths, 

per  cent. 

44 

15.52 

284 

54 

25.52 

212 

Between  2  and  5  years  of  application 
Between  5  and  10  years  of  application 
More  than  10  years  prior  to  applica- 
tion          76  59.09  129 

174  100.13  174 


SYPHILIS,   DOUBTFUL, 


Actual 
deaths. 


More  than  2  years  prior  to  application     67 


Expected 
deaths. 

48.81 


Ratio  of  actual 
to  expected 
deaths, 
per  cent. 

137 


HamilP  also  says  that  syphilitics  as  a  class  are  a  poor  risk. 
Thirty-four  American  companies  have  issued  policies  on 
cases  that  were  believed  to  be  cured.  That  is,  they  were 
only  insured  after  great  care  had  been  exercised  to  eliminate 
all  doubtful  cures  in  so  far  as  such  elimination  was  possible 
and  after  the  lapse  of  sufficient  time  to  warrant  the  belief 
that  cures  had  been  effectual.  This  class  has  been  under 
observation  for  thirty  years.  The  result  is  unsatisfactory, 
for  the  mortality  was  133  per  cent.  That  is,  where  100 
deaths  were  expected  133  occurred. 

It  must  be  remembered  in  considering  insurance  figures 
that  the  possibility  of  an  antecedent  syphilitic  infection 
cannot  be  excluded,  and  indeed  undoubtedly  occurs  often 
among  the  presumably  normal  class  on  whom  the  expectancy 
is  based.  This  fact  emphasizes  the  increased  mortality 
observed  among  known  syphilitics  and  the  potentialities 
of  syphilis  as  a  killing  disease.  More  and  more  syphilis  has 
come  to  be  recognized  as  a  very  fatal  disease,  and  this  fact 
adds  greatly  to  its  importance  from  a  public  health  stand- 
point. A  disease  would  not  become  a  sanitary  menace,  even 
if  it  were  very  prevalent,  if  only  it  were  innocuous,  but  when 
it  is  both  very  prevalent  and  very  fatal,  its  influence  on  the 
mortality  becomes  of  the  greatest  importance  to  the  sani- 
tarian.    Fisk^^  has  pointed  out  that  while  the  death-rate 


INTRODUCTION  23 

from  the  usual  infectious  diseases  has  steadily  declined  during 
the  past  three  decades  the  death-rates  for  apoplexy,  kidney 
diseases  and  heart  and  circulatory  disturbances  have  steadily 
increased.  This  increase  has  been  so  marked  that  in  1912 
the  death-rate  for  organic  heart  disease  exceeded  the  rate 
for  all  forms  of  tuberculosis.  The  death-rate  during  the 
early  years  of  life  is  being  decreased,  but  it  is  increasing 
during  the  period  beyond  forty  years  of  age.  Is  not  the  influ- 
ence of  the  syphilitic  infection  that  pervades  society  observ- 
able here? 

The  danger  of  syphilis  to  the  general  public  has  been  inves- 
tigated by  Blaisdell"  who  selected  60  cases  in  the  early 
stages  of  the  disease  as  they  presented  themselves  in  the  skin 
department  of  the  Boston  dispensary.  Blaisdell  found  that 
between  the  time  of  their  infection  to  the  time  of  their  first 
appearance  in  the  clinic  for  treatment  these  60  cases  exposed 
34  people  to  the  disease  by  coitus,  442  through  family  or 
boarding-house  life  and  651  by  occupational  association,  or 
1227  people  in  all.  Of  the  476  people  so  exposed  by  coitus 
or  family  life,  5  were  definitely  ascertained  to  have  become 
infected,  4  through  intercourse  and  1  by  being  kissed  by  the 
mother,  while  of  the  remaining  exposed  persons  no  definite 
information  was  obtainable.  It  may  be  assumed  that  these 
60  cases  of  fresh,  untreated  syphilis  are  the  direct  result  of 
60  other  definitely  active  foci  of  infection  in  the  community. 
Of  these  60  foci  only  2  were  brought  under  medical  control 
as  the  result  of  investigation  of  the  source  of  infection. 

The  danger  of  syphilis  to  the  community  or  individual  is 
increased  in  proportion  to  the  inadequacy  of  the  treatment 
received  by  those  suffering  with  the  disease.  A  careful 
investigation  of  this  portion  of  the  clinic  was  made  in  order 
to  find  out  how  effectively  patients  follow  their  doctor's 
advice.  Seventy  per  cent,  of  the  patients  made  less  than  five 
visits,  a  number  insufficient  in  most  cases  to  relieve  even  the 
symptoms  for  which  they  entered  the  clinic.  Only  9  per  cent, 
came  more  than  eight  times.  The  menace  to  the  public  in 
this  situation  is  sufficiently  clear. 

Facts  such  as  these  indicate  that  a  careful  consideration 
of  syphilis  in  its  relation  to  public  health  should  be  of  value. 


24  SYPHILIS  AND  PUBLIC  HEALTH 

In  considering  the  sanitary  measures  to  be  taken  against  a 
disease  such  as  syphihs,  whose  immediate  cause  is  known,  the 
important  factors  to  be  discussed  are  (1)  the  incidence  of  the 
disease;  (2)  accurate  information  as  to  the  various  methods 
of  transmission;  (3)  the  practicabihty  of  the  various  methods 
that  may  be  suggested  for  preventing  this  transmission. 

An  endeavor  has  therefore  been  made  in  this  work  to  collect 
as  much  information  as  possible  with  regard  to  the  prevalence 
of  syphilis,  more  particularly  in  the  United  States,  both  by 
searching  the  literature  and  by  original  investigation. 

The  methods  by  which  syphilis  is  transmitted  are  pretty 
thoroughly  understood,  and  it  has  therefore  been  possible 
to  collect  a  considerable  amount  of  information  on  this  point, 
including  the  proportion  of  genital  and  extragenital  syphilis 
and  the  method  of  transmission  in  syphilis  insontium. 

The  methods  that  may  be  taken  to  reduce  the  prevalence 
of  syphilis  have  been  considered  under  the  heads  of  personal 
prophylaxis,  or  those  measures  that  any  individual  may  take 
on  his  own  initiative,  and  public  health  measures  or  sanitary 
regulations  that  can  only  be  enforced  by  the  community 
by  statute  or  through  the  activity  of  the  public  health  officer. 
The  latter  has  necessitated  a  partial  discussion  of  the  old 
subject  of  prostitution.  It  would  at  first  hardly  seem  as  if 
anything  new  could  be  said  on  a  theme  that  has  been  worn 
almost  threadbare,  but  the  Wassermann  reaction  and  the  use 
of  salvarsan  throw  a  new  light  on  all  phases  of  the  subject 
of  syphilis.  The  possibility  of  controlhng  the  amount  of 
syphilis  acquired,  whether  by  prostitution  or  general  immor- 
ality, by  means  of  enforced  systematic  treatment,  has  not  yet 
been  given  the  serious  consideration  that  the  subject  merits. 

The  importance  of  the  subject  justifies  its  discussion.  The 
writer  has  never  had  experience  in  public  health  work  in 
civil  communities,  but  has  had  opportunities  for  studying 
the  subject  in  the  army,  which  may  fairly  be  called  excep- 
tional, in  that  they  include  a  long  period  of  actual  service 
with  troops  both  in  the  field  and  in  garrison,  followed  by 
four  years  of  continuous  experience  with  the  laboratory  side 
of  the  problem,  during  which  time  the  facilities  afforded  by  the 
library  of  the  Surgeon-General  have  been  readily  accessible. 


INTRODUCTION  25 

Hence,  while  the  results  of  this  investigation  are  presented 
with,  it  is  hoped,  due  modesty  the  writer  has  the  temerity 
to  believe  that  they  may  have  some  value. 

REFERENCES. 

1.  Osier:     The  Campaign  Against  Syphilis,  Lancet,  1917,  i,  789. 

2.  Downing:  Syphilis  and  Lung  Disease,  Boston  Med.  and  Surg.  Jour., 
1915,  clxxii,  898. 

3.  Lenz:  Ueber  die  Haufigkeit  der  Syphilitischen  Sklerose  der  Aorta 
relativ  zur  gewohnlichen  Athero-sklerose  und  zur  Syphilis  uberhaupt,  Med. 
Klinik,  1913,  ix,  955. 

4.  Brooks:     The  Heart  in  Syphilis,  Am.  Jour.  Med.  Sc,  1913,  cxlvi,  513. 

5.  Stengel  and  Austin:  Syphilitic  Nephritis,  Am.  Jour.  Med.  Sc,  1915, 
cxlix,  12. 

6.  Leredde:  Etude  sur  la  Mortalite  due  h,  la  Syphilis,  Revue  generale 
de  clin.  et  de  therapeutique,  1913,  xxvii,  611. 

7.  Mattauschek  and  PUcz:  Ueber  die  Weiteren  Schicksale  4134  Katam- 
nesish  verfolgter  Falls  luetischer  Infection,  Med.  Klinik,  1913,  ix,  1544. 
See  also  Waldvogel  and  Stissenguth:  Die  Folgen  der  Lues,  Berl.  klin. 
Wchnschr.,  1908,  xlv,  1213. 

8.  Sehroeder:  Syphilis  in  Relation  to  Life  Insurance,  Med.  Record, 
1914,  Ixxxv,  691.  See  also  Solomonson:  Syphilis  Mortality,  Med.  Exam, 
and  Practitioner,  1905,  xv,  605. 

9.  Hamill:  Syphilis  from  a  Life  Insurance  Stand-point,  Am.  Jour. 
Dermat.  and  Gen.-urin.  Dis.,  1909,  xiii,  144. 

10.  Fisk:     Increasing  Mortality  in  the  United  States,  New  York  Med. 
Jour.,  1916,  ciii,  97. 

11.  Blaisdell:     The    Menace    of    SyphUis    to    the    Clean-living    Public, 
Boston  Med.  and  Surg.  Jour.,  1915,  clxxii,  476. 


CHAPTER  I. 
THE  PREVALENCE  OF  SYPHILIS. 

It  is  specially  important  to  obtain  accurate  knowledge 
with  regard  to  the  prevalence  and  distribution  of  s;^q3hilis 
if  any  attempt  is  to  be  made  to  control  the  disease.  Such 
information  is  necessary  not  only  to  enable  public  health 
officials  to  adopt  appropriate  measures,  but  especially  to 
enlist  the  support  of  public  opinion,  without  which  no 
measures  can  be  effective.  Mcllroy^  in  referring  to  the 
recent  investigation  of  the  British  Royal  Commission  into 
the  prevalence  of  venereal  diseases  in  Great  Britain,  said: 
"One  could  almost  have  wished  that  the  Royal  Commission 
had  not  been  appointed  until  some  time  later,  when,  as  the 
result  of  fiu-ther  investigation,  the  evidence  of  the  preval- 
ence of  venereal  diseases  more  especially  among  the  poorer 
classes,  would  have  been  so  overwhelming  that  the  public 
itself  would  have  awakened  to  a  sense  of  the  dangers  and 
the  necessity  for  some  measm-es  of  reform."  It  will  be  the 
object  of  this  chapter  to  make  some  attempt  toward  supply- 
ing this  need. 

A  great  many  estimates  or  guesses  have  been  made  as  to  the 
prevalence  of  syphilis  in  different  countries.  Most  of  these 
are  of  little  present  value  for  several  reasons.  Many  estimates 
have  been  based  entirely  upon  the  number  of  known  cases 
appearing  for  treatment,  and  are  therefore  undoubtedly 
underestimates.  There  is  no  certainty  that  the  figures 
obtained  in  another  country  will  apply  to  our  own,  and, 
finally,  in  most  cases  an  attempt  has  been  made  to  estimate 
the  prevalence  of  syphilis  in  the  community  as  a  whole. 
Now,  society  is  not  homogeneous,  but  consists  of  numerous 
strata  or  classes,  and  each  class  is  composed  of  males  and 
females  of  all  different  ages.     The  incidence  of  disease  is 


INCIDENCE  IN  DIFFERENT  GROUPS  OF  POPULATION  27 

known  to  vary  considerably  in  different  classes,  and  because 
of  its  peculiar  manner  of  spread,  syphilis  varies  more  in  the 
different  classes,  races,  sexes  and  ages  than  most  other  dis- 
eases. If  20  per  cent,  of  the  males  and  1  per  cent,  of  the 
females  of  a  certain  class  are  infected  with  syphilis  we 
obviously  create  an  erroneous  impression  when  we  state  that 
11  per  cent,  of  the  community  are  syphilitic,  for  this  rate  is 
ten  times  too  high  for  the  women  and  only  about  half  the 
incidence  among  the  men,  and,  moreover,  the  figures  for 
another  class  of  the  population  would  be  totally  different. 

Incidence  in  Different  Groups  of  the  Population.  —  Dr. 
Stevenson  (synopsis  of  the  final  report  of  the  Royal  Com- 
mission on  Venereal  Diseases)  has  tabulated  all  deaths 
from  syphilis  and  sequential  diseases  in  eight  groups  as 
follows : 

Class.  Social  status. 

1 Upper  and  middle 

2 Between  1  and  3 

3 Sldlled  labor 

4 Between  3  and  5 

5 Unskilled  labor 

6 Textile  workers 

7 Miners' 

8  ....      .  Agricultural  laborers                  108                 VIII 

In  this  classification  the  chief  points  shown  are :  (a)  the 
high  incidence  in  classes  5,  4,  1  and  the  lower  incidence  in 
8,  7,  6;  {h)  unskilled  labor  was  highest  on  all  counts  except 
locomotor  ataxia,  in  which  it  was  the  second  highest.  The 
upper  classes  were  second  in  general  paralysis  of  the  insane 
and  aneiu-ysm,  the  highest  in  locomotor  ataxia  and  the  third 
in  total  deaths  from  syphilis.  If  these  figures  are  correct 
it  follows  that  syphilis  is  the  most  frequent  in  the  highest 
and  lowest  social  classes  while  agricultural  laborers  are 
relatively  free.  Such  statistics,  which  are  based  on  deaths 
alone,  however  suggestive,  cannot  be  accepted  without 
reservation.  The  poor  naturally  tend  to  die  in  institutions 
where  the  diagnosis  is  more  apt  to  be  correct,  and  in  any  case 
the  deaths  are  only  one  index  of  the  prevalence  of  syphilis, 
though  other  things  being  equal  it  should  be  a  correct  index. 


Death-rate. 

Orde 

302 

III 

280 

IV 

264 

v 

304 

II 

429 

I 

186 

VI 

177 

VII 

28        THE  PREVALENCE  OF  SYPHILIS 

Such  figures,  however,  bear  out  the  statement  that  a  detailed 
study  of  the  various  social  groups  must  be  made  before  we 
will  have  accurate  information  as  to  the  distribution  of 
syphilis  in  the  community. 

While  it  is  obviously  impossible  at  present  to  obtain 
satisfactory  evidence  with  regard  to  the  incidence  of  syphilis 
in  all  these  various  component  parts  of  the  population  of  the 
United  States,  an  attempt  has  been  made  to  present  such 
data  as  are  obtainable  in  the  literature,  and  in  addition  the 
writer  has  been  engaged  for  the  past  four  years  in  making 
a  series  of  Wassermann  surveys  of  certain  groups  of  the  popu- 
lation. 

There  may  be  a  question  in  the  minds  of  some  as  to  the 
value  of  such  surveys.  A  single  positive  Wassermann 
reaction  in  the  absence  of  clinical  evidence  does  not  prove 
that  the  patient  is  syphilitic,  and  if  the  same  examination 
is  applied  to  thousands  instead  of  to  individuals,  will  not 
the  error  be  multiplied?  I  do  not  think  so.  The  error  in  this 
reaction  as  I  have  used  it  is  apparently  less  than  1  per  cent. : 
that  is,  of  all  double  plus  reactions  that  could  be  investigated 
less  than  1  per  cent,  were  presumably  non-syphilitic.  While 
it  is  most  important  to  consider  this  error  from  the  stand- 
point of  the  individual  patient,  it  is  not  a  matter  of  impor- 
tance in  estimating  the  percentage  of  syphilis  in  a  certain 
group  by  means  of  this  test.  However,  throughout  the  dis- 
cussion, a  distinction  is  maintained  between  estimates  made 
by  various  authorities  and  the  actual  facts  as  obtained  by 
statistical  or  scientific  investigation.  It  is  important  to  note 
that  in  forming  conclusions  as  to  the  prevalence  of  syphilis 
both  the  reliability  of  the  investigator  and  the  thoroughness 
of  the  examination  must  be  taken  into  account.*  The 
percentage  is  always  higher  the  more  thorough  the  exami- 
nation is  made.  A  clinical  examination  combined  with  a 
Wassermann  test  always  shows  a  greater  number  of  syphilitics 
than  is  detected  by  either  test  alone.  This  fact  indicates 
that  the  estimates  based  on  the  Wassermann  reaction  alone 
are  probably  conservative.     The  highest  and  probably  the 

*  The  Wassermann  reaction  used  by  the  writer  in  his  investigations  is 
described  in  the  appendix,  p.  265. 


STATISTICS  FROM  OTHER  COUNTRIES  29 

most  accurate  figures  have  been  obtained  as  the  result  of 
certain  postmortem  observations,  of  which,  unfortunately, 
there  are  only  too  few. 

STATISTICS  FROM  OTHER  COUNTRIES. 

While  the  main  purpose  is  to  deal  with  the  prevalence  of 
syphilis  in  the  United  States  a  few  observations  from  other 
countries  may  be  of  value  as  a  basis  of  comparison. 

Russia. — According  to  Scheuer,^  syphilis  is  widespread  in 
Russia,  where  from  50  to  60  per  cent,  of  the  cases  are  due  to 
extragenital  infection,  and  the  disease  has  practically  lost 
its  characteristics  as  a  sexual  disease  and  has  become  a  con- 
tagious family  disease.  Sandberg^  has  described  remote 
villages  in  the  District  of  Koslow  where  almost  the  whole 
population,  old  and  young,  were  infected  with  syphilis,  and 
where  hardly  a  house  could  be  found  in  which  there  was  not 
some  person  infected.  The  peasants  live  herded  together 
in  great  poverty  and  filth,  of  which  some  conception  may 
be  obtained  by  the  statement  that  from  twenty  to  thirty 
men  may  live  in  a  house  hardly  18  feet  square.  Sandberg 
concludes  that  20.6  per  cent,  of  all  ambulatory  patients 
were  treated  for  syphilis,  but  that  the  actual  percentage  of 
syphilis  must  be  much  higher  than  this  which  represents 
only  those  in  the  active  stages  of  the  disease.  In  some 
villages  the  syphilization  of  the  entire  population  has  been 
accomplished,  and  the  disease  is  equally  distributed  among 
men,  women  and  children,  most  of  the  infections  being 
extragenital.  Scheuer  also  states  that  Generopitorozeff* 
described  the  epidemic  of  syphilis  in  the  Parafiew  District 
of  the  Government  of  Tschernigow.  This  consisted  of  six 
villages,  with  a  population  of  9500,  in  which,  according  to 
accurate  lists,  only  about  5  per  cent,  of  the  people  are  not 
syphilitic;  66.1  per  cent,  of  the  cases  were  hereditary,  17.3 
per  cent,  were  infected  by  close  contact,  11.9  per  cent,  in 
unknown  ways  and  only  4.7  per  cent,  were  infected  by  sexual 
contact.    In  such  places  syphilis  ruins  the  people  physically 

*  Wratch,  1901,  No.  38. 


30        THE  PREVALENCE  OF  SYPHILIS 

and  mentally,  and  is  the  greatest  hygienic  problem  of  the 
Russian  peasant  life. 

Natm-ally,  these  are  "horrible  examples,"  and  the  incidence 
of  syphilis  in  Russia  as  a  whole  can  be  nothing  like  so  high. 
Accurate  figures  as  to  the  prevalence  cannot  be  obtained,  but 
that  it  is  a  great  sanitary  problem  throughout  Russia  may 
be  gathered  from  the  following  statistics  published  by 
Rabinowitsch.^  These  figures  are  claimed  to  give  the  number 
of  syphilitic  patients  treated  in  hospitals  and  dispensaries, 
and  can  therefore  represent  only  a  small  proportion  of  the 
actual  number  of  infections.  Thus  in  the  United  States 
army  we  have  found  that  an  admission  rate  of  3  per  cent, 
usually  indicates  a  percentage  of  infection  ranging  between 
15  and  20. 

Number  of  cases         Percentage         Percentage 
Year.  of  syphilis.  from  cities.      from  country. 

1900 936,985  ?  ? 

1901 961,628  ?  ? 

1902 1,007,429  ?  ? 

1903 1,054,387  29.1  70.9 

1904 999,869  31.8  68.2 

1905 998,965  31.0  69.0 

1906 1,098,366  32.0  68.0 

1907 1,100,944  33.0  67.0 

1908 1,181,647  34.0  66.0 

1909  .......  1,199,148  33.0  67.0 

1910 1,214,915  33.0  67.0 

Feldhusen^  has  translated  the  paper  of  Tschlenoff,  who 
conducted  a  questionnaire  with  regard  to  the  sexual  life  of 
the  students  in  Moskow.  According  to  the  answers  received, 
67  per  cent,  had  bad  sexual  relations  before  their  entrance 
in  the  university;  7  per  cent,  were  married.  Of  the  total 
number  of  answers  received  from  2150  students,  69  per 
cent,  acknowledged  sexual  intercourse  outside  the  marriage 
relation.  Half  of  these  commenced  between  the  ages  of 
fourteen  and  seventeen  years,  the  majority  or  22  per  cent, 
having  had  their  first  intercourse  in  the  sixteenth  year;  41 
per  cent,  of  the  first  exposures  were  with  prostitutes,  39  per 
cent,  with  servant  girls  and  10  per  cent,  with  married  women. 

In  regard  to  venereal  diseases,  523,  or  25.3  per  cent., 
acknowledged  infection.    19.6  per  cent,  of  the  students  had 


STATISTICS  FROM  OTHER  COUNTRIES  31 

had  gonorrhea;  3  per  cent,  had  had  chancroid,  and  2.7  per 
cent,  acknowledged  syphihs. 

Favre®  also  sent  a  questionnaire  to  the  students  of  the 
University  and  higher  technical  schools  at  Charkow.  The 
replies  were  anonymous  and  1298  answers  were  received. 
These  indicated  that  67  per  cent,  of  these  students  had  had 
sexual  intercourse  before  entering  the  University.  In  the 
majority  of  cases  the  first  step  was  taken  at  seventeen  years 
and  more  or  less  regular  sexual  indulgence  began  about  two 
years  later.  The  incidence  of  venereal  diseases  was  high, 
47.2  per  cent,  suffering  from  gonorrhea;  10.8  per  cent,  from 
chancroid,  and  6.9  per  cent,  from  syphilis. 

Such  figures  can  make  little  pretence  toward  scientific 
accuracy,  but  at  least  give  some  indication  of  the  extent  of 
venereal  infections,  including  syphilis,  and  throw  some  light 
on  the  early  age  at  which  many  such  infections  are  acquired. 
The  evidence  indicates  that  the  majority  of  infections  in  the 
United  States  are  acquired  somewhat  later  in  life,  namely, 
from  twenty  to  twenty-five  years  of  age. 

Serbia. — Syphilis  has  been  demonstrated  thi'oughout  the 
whole  of  Serbia.  Statistics  completed  in  the  years  1898  and 
1899  show  a  proportion  of  2.6  cases  per  thousand  during 
the  first  year  and  2.43  during  the  second  year.  The  incidence 
is  higher  among  the  women,  namely,  2.93  per  thousand. 
These  actual  cases  of  the  disease  probably  indicate  an  inci- 
dence of  the  disease  of  from  5  to  10  per  cent,  of  the  popula- 
tion, since  only  clinical  cases  were  recorded.  It  is  stated  that 
infection  by  the  genital  route  is  comparatively  infrequent  and 
that  extragenital  infection  is  common.  ■' 

Asia  Minor. — An  article  by  von  Diiring-Pascha^  indicates 
that  conditions  in  Turkey  and  Asia  Minor  are  very  similar 
to  those  already  described  in  Russia.  Hereditary  syphilis 
is  much  more  widespread  than  the  sexually  acquired  type,  and 
in  all  places  except  the  cities,  prostitution  is  of  minor  impor- 
tance. The  disease  is  spread  largely  through  close  association 
and  uncleanliness  combined  with  ignorance  of  the  danger  of 
extragenital  infection.  The  natives  drink  from  vessels  with  a 
sharp  spout  and  pass  the  water  pipe  and  cigarettes  from 
mouth  to  mouth  with  sublime  carelessness.    In  one  village 


32  THE  PREVALENCE  OF  SYPHILIS 

that  was  investigated,  out  of  2500  inhabitants,  495,  or  19.8 
per  cent.,  were  found  to  suffer  with  obvious  lesions  of  syphilis. 
A  Wassermann  reaction  would  probably  have  shown  the 
entire  population  to  be  syphilitic.  The  general  distribution 
of  the  actual  cases  is  shown  in  the  following  table: 

OVER  TWELVE   YEARS    OF  AGE. 

Men.  Women.  Total. 

Early  symptoms 47  52  99 

Late  symptoms 109  135  244 

Total 156  187  343 

UNDER   TWELVE    YEARS    OF  AGE. 

Boys.  Girls.  Total. 

Early  symptoms  ......        66  61  127 

Late  symptoms 16  9  25 

Total 82  70  152 

Grand  total 495 

The  same  conditions  may  very  possibly  occur  throughout 
a  large  part  of  Asia.^  Jefferys  and  MaxwelP°  state  that 
"syphilis  is  met  with  from  one  end  of  China  to  the  other, 
though  mild  in  type."  This  mildness  may  be  an  illusion 
owing  to  the  fact  that  many  of  the  more  serious  conditions 
may  never  be  seen  by  a  foreign  practitioner.  The  authors 
state,  however,  that  late  lesions  are  most  commonly  seen. 
No  attempt  to  determine  the  prevalence  of  the  disease  by 
Wassermann  surveys  or  intensive  observation  appears  to 
have  been  made. 

The  Tropics. — According  to  Scheube^^  syphilis  is  widespread 
over  almost  all  tropical  regions,  and  there  are  only  a  very 
few  places  in  the  heart  of  Africa,  New  Guinea  and  the  interior 
of  a  few  islands  where  the  disease  has  not  penetrated.  He 
states  that  it  is  undeniable  that  the  bearers  of  civilization 
have  also  always  introduced  syphilis.  After  its  introduction 
the  disease  often  spreads  through  extragenital  methods  of 
transmission,  owing  to  the  lack  of  clothes  and  close  and 
insanitary  contact;  and  as  the  disease  is  almost  never  treated, 
it  is  probable  that  whole  races  become  thoroughly  syphilized 
much  faster  than  they  become  civilized. 


STATISTICS  FROM  OTHER  COUNTRIES  33 

It  is  unfortunate  that  no  systematic  investigation  into  the 
prevalence  of  syphiHs  among  the  natives  of  the  PhiHppines 
has  been  made.  It  is  known,  however,  that  the  disease  is 
exceedingly  common,  and  the  rates  for  syphilis  among  soldiers 
have  always  been  much  higher  in  the  Philippines  than  in  the 
United  States.  This  is  undoubtedly  partly  due  to  the  relaxa- 
tion of  morals  that  follows  when  men  are  shipped  "east  of 
the  Suez  where  there  aint  no  ten  commandments;"  but  this 
is  not  the  entire  explanation.  Outside  of  some  of  the  larger 
cities  there  are  no  regular  prostitutes,  but  all  the  native 
women  are  free  and  easy  with  the  whites.  It  follows,  there- 
fore, that  syphilis  is  very  common. 

Baermann^^  used  the  Wassermann  reaction  in  order  to 
determine  the  prevalence  of  syphilis  among  the  laborers  in 
Sumatra.  The  laboring  colony  consists  of  about  8000  (1000 
Chinese,  4000  Javanese  men  and  3000  Javanese  women). 
The  laborers  are  given  an  examination  twice  yearly  to 
detect  syphilis,  and  the  average  hospital  admissions  for  this 
disease,  following  three  different  examinations,  was  4.5  per 
cent.,  3.7  per  cent.,  and  2.5  per  cent.  The  falling  rate  is 
explained  as  the  result  of  consistent  treatment.  The  Wasser- 
mann reaction  was  performed  on  900  sera  from  contract 
laborers  who  appeared  healthy  and  had  no  manifest  syphilis 
or  yaws,  with  the  following  result : 

Positives  in  percentage. 
Men.  Women. 

Javanese  laborers  who  had  been  in  Sumatra  several 

years 17                 22 

Laborers  recently  arrived  from  Java       ....  16                  20 

Chinese 25 

Since  the  Wassermann  reaction  is  only  positive  in  about 
50  per  cent,  of  latent  syphilis,  Baermann  suggests  that  to 
ascertain  the  prevalence  of  syphilis  in  this  group  the  figures 
should  be  multiplied  by  two.  According  to  this  estimate, 
34  per  cent,  of  the  older  Javanese  laborers  suffer  from 
syphilis,  while  44  per  cent,  of  the  women  are  infected;  and 
among  recently  arrived  Javanese  laborers  the  males  suffer 
from  syphilis  in  32  per  cent,  and  the  females  in  40  per  cent. 
The  Chinese  males  were  estimated  at  from  50  to  60  per  cent. 
These  estimates  may  be  taken  for  what  they  are  worth,  but 
3 


34  THE  PREVALENCE  OF  SYPHILIS 

the  results  of  the  Wassermann  reaction  on  this  group  of  900 
apparently  healthy  natives  are  certainly  below  the  actual 
prevalence  of  the  disease.  At  least  the  4.5  per  cent,  of  those 
known  to  be  infected  must  be  added  to  obtain  a  correct  idea 
of  the  incidence  of  the  disease. 

Conditions  are  probably  not  much  better  in  the  tropical 
regions  of  America.  Rothschuh^^  stated,  in  1901,  that  he  was 
well  within  the  limits  of  safety  when  he  estimated  that  70  per 
cent,  of  the  male  population  of  Nicaragua  were  syphilitic, 
while  about  50  per  cent,  of  the  women  were  infected. 

Africa. — Schroedter^^  observed  syphilis  among  the  natives 
of  Southwest  Africa.  He  states  that  Livingstone  found  a 
tribe  in  the  interior  of  Africa  that  was  entirely  free  from 
syphilis.  Along  the  coast  where  contact  with  whites  has 
occurred,  syphilis  is  universal.  No  exact  statistics  as  to 
prevalence  are  given,  but  the  statement  is  made  that  the 
relative  prevalence  between  the  men  and  the  women  is  1 
to  10.  The  reason  is  that  the  women,  whether  married  or 
single,  practically  all  have  intercourse  with  the  whites.  It 
is  a  noteworthy  fact  that  whenever  Women  are  promiscuous, 
they  suffer  from  syphilis  to  a  greater  extent  than  the  males 
who  may  not  be  much  more  virtuous.  This  is  undoubtedly 
because  a  promiscuous  woman  will  have  intercourse  with  a 
number  of  males  much  greater  than  the  number  of  women 
with  whom  a  promiscuous  man  has  relations,  so  that  the 
female  is  much  more  liable  to  infection.  This  fact  explains 
the  higher  incidence  of  sjq^hilis  among  the  negro  women  in 
the  United  States. 

Broc^^  made  some  observations  concerning  syphilis  among 
the  inhabitants  of  Tunis,  and  says  that  it  is  excessively 
prevalent,  certain  physicians  believing  that  it  attacks  more 
than  two-thirds  of  the  population.  Of  8000  new  cases  pre- 
senting themselves  in  his  clinic  for  all  conditions,  he  saw  only 
9  chancres  but  more  than  500  cases  of  clear  secondary  or 
tertiary  lesions.  Thus,  6.3  per  cent,  of  all  his  cases  had 
clinical  manifestations  of  the  disease.  He  comments  on  the 
mild  course  of  the  disease  among  the  natives. 

Brock^^  made  a  clinical  examination  of  7660  consecutive 
natives  in  Basutoland  and  comes  to  the  conclusion  that 


STATISTICS  FROM  OTHER  COUNTRIES  35 

nearly  80  per  cent,  of  these  natives  have  detectable  mani- 
festations of  syphilis;  68  per  cent,  of  the  natives  have  an 
indurated  enlargement  of  the  epitrochlear  glands. 

Sicard  and  Levy-Valesi^'^  say  that  it  is  a  matter  of  general 
knowledge  that  syphilis  is  exceedingly  common  among  the 
Arabs  and  that  it  is  usually  benign  in  its  manifestations. 
They  performed  a  Wassermann  reaction  on  30  wounded 
Arabs  in  a  military  hospital.  These  men  were  between 
twenty  and  thirty-five  years  of  age  and  none  of  them  suffered 
from  manifest  lesions  of  the  disease.  Of  these  30  cases,  6,  or 
20  per  cent.,  were  positive;  2  gave  a  partial  reaction  and  22 
were  negative. 

Ringenbach  and  Guyomarch^^  examined  some  4000  people 
in  the  French  Congo,  and  found  4  per  cent,  of  obvious  ter- 
tiary lesions.  As  this  is  necessarily  only  a  small  amount  of 
the  actual  syphilitic  infection  that  must  be  present,  they 
come  to  the  conclusion  that  the  disease  is  widespread  and 
common. 

Turning  now  to  countries  where  conditions  are  more  nearly 
like  those  in  the  United  States  a  few  references  may  be 
presented  from  each  of  the  following  countries: 

Germany. — Blaschko,^^  in  1892,  estimated  that  for  the  pre- 
vious fifteen  years  there  was  a  yearly  incidence  of  5000 
fresh  cases  of  syphilis  to  an  average  population  of  1,270,000, 
or  about  4  per  cent.,  and  concluded  that  at  least  10  to  12  per 
cent,  of  the  adult  population  either  have  or  have  had  syphilis. 
If  there  were  4  per  cent,  of  fresh  cases  annually  this  is  evi- 
dently a  very  conservative  estimate.  Blaschko  also  gives 
the  following  figures  for  the  troops  of  the  Berlin  garrison: 

All  venereal 

diseases,  Syphilis, 

Year.                                                                                      per  cent.  per  cent. 

73  to  78 56.3  11.3 

78to83      .      . 51.8  9.8 

83  to  88 36.8  7.8 

Lenz^"  stated  in  1910  that  of  all  the  men  who  died  in  Berlin 
in  the  year  1900  hardly  10  per  cent,  were  free  from  syphilis, 
and  that  in  the  whole  of  Prussia  at  least  22  per  cent,  of  the 
adult  males  contract  syphilis  at  some  time  during  their  life. 


36        THE  PREVALENCE  OF  SYPHILIS 

Pinkus^^  wrote  in  1912  that,  "Roughly  speaking,  one  may  say 
that  most  German  men  have  had  gonorrhea  and  about  1  in 
5  syphilis."  Erb  found  that  out  of  10,000  cases  of  all  varieties 
of  disease  in  his  practice,  21  per  cent,  had  syphilis,  and  he 
believed  that  12  per  cent,  of  the  adult  population  of  Berlin 
were  infected.  These  are  all  estimates  of  more  or  less  signifi- 
cance.   The  following  studies  may  also  be  quoted : 

Heller,^"  in  1909,  presented  collected  statistics  as  to  the 
prevalence  of  hereditary  syphilis  in  Berlin.  Thus  he  quotes 
Neumann  and  Oberwarth,  who  investigated  62,221  children 
treated  during  fifteen  years  and  found  1.4  per  cent,  of  heredi- 
tary syphilis  among  the  legitimate  and  2.53  per  cent,  among 
the  illegitimate.  Taking  only  nursing  children  during  1904, 
2.81  per  cent,  of  legitimate  and  3.43  per  cent,  of  illegitimate 
babies  were  syphilitic.  The  figures  from  the  Children's 
Polyklinik  were  lower.  From  1872  to  1882,  of  28,000  children, 
254,  or  0.9  per  cent.,  were  syphilitic.  Von  Cassel  in  another 
series  of  17,448  nursing  children  found  207,  or  1.18  per  cent., 
to  be  syphilitic.  When  one  considers  that  the  Wassermann 
reaction  was  not  yet  in  use  and  that  this  represents  merely 
the  obvious  syphilis,  some  idea  may  be  formed  not  only  as 
to  the  amount  of  hereditary  syphilis  in  Berlin,  but  also  as  to 
the  amount  of  syphilis  among  the  adult  population  which 
must  have  been  many  times  higher.  Epstein,^^  in  1913, 
examined  236  nursing  children  in  an  institution  during  the 
first  weeks  of  their  life.  The  Wassermann  reaction  was  used 
in  all  cases,  and  8,  or  3.3  per  cent.,  were  shown  to  be  luetic. 

Kurner^^  applied  the  Wassermann  reaction  to  the  weak- 
minded,  with  the  intention  of  obtaining  some  information 
as  to  the  prevalence  of  syphilis  in  the  community  at  large. 
The  investigation  was  limited  to  inmates  under  forty  years 
of  age  in  the  Institution  for  the  Weak-minded  in  Wiirtemberg; 
1244  patients  were  investigated,  of  whom  119,  or  9.6  per  cent., 
gave  a  positive  reaction;  88  of  the  positives  gave  a  history, 
and  it  was  found  that  63  of  them  came  from  cities  while  25 
came  from  the  country.  This  indicates  the  greater  incidence 
of  the  disease  in  the  cities.  In  this  series  about  15  per  cent, 
of  idiots  and  5  to  6  per  cent,  of  epileptics  had  a  positive 
Wassermann. 


STATISTICS  FROM  OTHER  COUNTRIES  37 

Lippmann^^  investigated  the  relation  between  idiocy  and 
syphilis  and  gave  references  to  the  previous  literature  on  this 
subject,  among  which  may  be  mentioned  the  work  of  Piper, 
who  performed  the  Wassermann  on  316  idiots,  of  whom  16, 
or  5  per  cent.,  were  positive.  Lippmann  examined  136 
epileptics,  of  whom  5,  or  3.6  per  cent.,  were  positive.  He 
then  examined  121  idiots,  of  whom  78  were  less  than  fourteen 
years  of  age,  and  all  were  under  twenty  years  of  age;  16,  or 
13.2  per  cent.,  gave  a  positive  Wassermann.  Lippmann 
quotes  the  results  of  Plant,  who  investigated  a  series  of  52 
children  of  luetic  descent  and  found  only  44  per  cent,  positive 
by  the  Wassermann  reaction.  Lippmann  therefore  estimates 
that  of  his  121  idiots  the  percentage  actually  infected  with 

syphilis  is  13.2  by  -jj,  or  30  per  cent.    The  cases  were  also 

studied  for  evidence  of  hereditary  syphilis,  and  as  the  result 
of  these  findings  combined  with  the  Wassermann  reaction, 
Lippmann  estimated  that  over  40  per  cent,  of  these  idiots 
were  syphilitic. 

Dean^"  examined  and  performed  the  Wassermann  reaction 
on  330  cases  of  idiocy  at  the  Potsdam  asylum.  Of  these, 
51,  or  15.4  per  cent.,  gave  a  positive  reaction. 

Hubert"  studied  the  prevalence  of  syphilis  among  the 
patients  at  the  medical  clinic  of  Dr.  Romberg  at  Munich. 
The  investigation  lasted  from  October,  1912,  to  July,  1915, 
and  included  a  complete  clinical  study.  The  Wassermann 
reaction  was  used,  but  not  on  all  patients.  Out  of  8562 
patients  so  studied,  759,  or  8.8  per  cent.,  were  luetic.  Among 
the  4739  males,  405,  or  8.5  per  cent.,  were  luetic,  while 
among  the  3903  females,  354,  or  9  per  cent.,  were  luetic. 
Undoubtedly  the  percentages  would  have  been  higher  had 
the  Wassermann  reaction  been  used  on  all  patients. 

At  various  times^^  efforts  have  been  made  to  take  a  census 
of  the  venereal  patients  in  various  cities,  but  these  attempts 
give  little  information  as  to  the  amount  of  syphilis  actually 
present,  as  there  is  no  proof  that  the  physicians  all  reported 
their  cases ;  and,  moreover,  such  figures  include  only  cases  which 
appeared  of  their  own  volition  for  treatment,  and  the  much 
greater  number  of  latent  cases  is  not  shown  by  such  figures. 


38        THE  PREVALENCE  OF  SYPHILIS 

Budapest. — Torok^^  made  an  estimate  of  the  prevalence  of 
syphilis  in  Budapest,  based  upon  the  proportion  of  fresh 
cases  of  syphilis  acquired  by  the  members  of  certain  work- 
men's associations  for  whom  special  hospital  facilities  were 
provided.  Thus,  in  1892  these  associations  contained  30,000 
members  (23,500  men  and  6500  women).  Of  these,  124  men 
and  5  women  were  treated  for  fresh  infections  with  syphilis. 
In  1893,  of  44,700  members  (36,000  men  and  8700  women) 
138  men  and  10  women  acquired  syphilis.  As  these  cases, 
coming  to  the  hospital,  represent  only  a  small  number  of  the 
total  number  of  infections,  Torok  estimates  that  from  2.5 
to  2.9  per  cent,  of  the  total  adult  population  and  from  4.5 
to  5.3  per  cent,  "of  the  adult  males  acquire  syphilis  annually. 

Belgium. — Bayet^°  estimated  in  1908,  as  the  result  of  his 
four  years  of  observation  of  syphilis  in  Brussels,  that  26  per 
cent,  of  the  men  of  the  working  classes  of  Brussels  acquired 
syphilis  and  that  most  of  them  transmitted  it  to  their  wives 
and  sometimes  to  their  children. 

France. — Fournier  estimated  that  15  per  cent,  of  the  adult 
population  of  Paris  were  infected  with  syphilis.  While  this 
estimate  is  subject  to  the  same  criticism  applying  to  other 
estimates  it  is  but  fair  to  add  that  it  is  based  on  what  is 
probably  the  largest  clinical  experience  of  any  one  man  in 
France,  and,  for  that  matter,  probably  in  any  part  of 
the  world.  An  estimate  of  the  annual  mortality  caused  by 
syphilis  in  Paris  has  already  been  presented  in  the  introduc- 
tion. 

Raviart,  Breton  and  Petit,^^  in  1908,  published  the  results 
of  the  Wassermann  reaction  applied  to  the  spinal  fluids  of 
400  inmates  of  the  insane  asylum  at  Armentieres;  76  were 
cases  of  general  paralysis,  of  whom  71  gave  a  positive  reac- 
tion. The  remainder  of  the  cases  comprised  the  various 
forms  of  dementia,  idiocy  and  imbecility.  Of  these  400  cases, 
165,  or  41.25  per  cent.,  gave  a  positive  reaction.  Only  21 
of  these  cases  had  clinical  evidences  of  syphilis.  Excluding 
the  cases  of  general  paralysis  and  5  cases  associated  with 
tabes,  26.7  per  cent,  of  the  remainder  were  syphilitic.  The 
intake  of  an  insane  asylum  cannot  have  a  very  much  higher 
percentage  of  syphilis  than  the  general  population  if  the 


STATISTICS  FROM  OTHER  COUNTRIES  39 

insanity  specifically  caused  by  syphilis  is  deducted.    The  sex 
and  age  of  these  insane  was  not  stated. 

Calmette,  Breton  and  Couvreur^^  examined  blood  from  the 
cord  in  the  case  of  103  consecutive  women  confined  at  the 
Maternity  Hospital  of  Seclin.  There  were  16  positive  reac- 
tions, or  15.5  per  cent.  Most  of  these  were  respectable 
married  women,  but  in  a  few  cases  the  father  was  unknown. 

D 'Astros  and  Teissonniere^^  performed  the  Wassermann 
reaction  on  500  foundling  infants;  321  of  these  infants  were 
from  four  to  fifteen  days  old,  109  were  from  fifteen  days  to 
one  month,  42  were  between  two  and  three  months,  4  were 
from  six  months  to  one  year  of  age,  and  3  were  from  one  year 
to  fifteen  months  of  age.  An  alcoholic  extract  of  syphilitic 
liver  was  used  as  antigen;  477  of  these  infants  gave  a  negative 
reaction  and  18,  or  3.6  per  cent,  gave  a  positive  reaction. 
The  authors  conclude  that  approximately  4  per  cent,  of  these 
foundlings  have  a  positive  Wassermann  reaction  and  are 
presumably  syphilitic. 

Leduc^^  stated  that  of  1213  women  admitted  for  pregnancy 
to  the  maternity  hospital  at  Tenon,  94,  or  7.7  per  cent., 
presented  certain  clinical  signs  of  syphilis.  The  Wassermann 
reaction  was  not  performed. 

Bubendorf^'^  investigated  the  prevalence  of  syphilis  among 
the  laborers  in  the  mines  of  Briey  and  Longwy.  The  Wasser- 
mann reaction  was  apparently  not  used  and  the  estimate 
was  based  on  clinical  cases  and  was  evidently  a  very  sketchy 
affair.  The  prevalence  of  the  disease  varied  considerably 
in  different  districts,  but  was  considered  to  be  increasing. 
The  following  table  gives  the  population  in  some  of  the  dis- 
tricts, with  the  estimated  incidence  of  syphilis: 

Estimated 
Industrial  Population,  syphilis, 

center.  1912.  per  cent. 

Homecourt 10,192  4.5 

Joeuf 10,100  4.8 

Landres 2,800  25.0 

Pienne 3,700  25.0 

Auboue 4,600  6.7 

Moutiers 1,820  2.4 

Tucquegnieux 2,265  6  to  8 

Valleroy 1,500  16.0 

Sancy 860  6  to  8 


40        THE  PREVALENCE  OF  SYPHILIS 

Letulle  and  Bergeron^^  performed  the  Wassermann  reac- 
tion on  a  large  number  of  cases  at  the  hospital  Boucicaut. 
They  found  that : 

Of  253  chronic  nervous  diseases,  136,  or  53.7  per  cent., 
gave  a  positive  Wassermann. 

Of  168  vascula'r  lesions,  90,  or  59.5  per  cent.,  gave  a  positive 
Wassermann. 

Of  116  kidney  cases,  34,  or  29.3  per  cent.,  gave  a  positive 
Wassermann. 

Of  75  cases  of  cirrhosis,  34,  or  45.3  per  cent.,  gave  a  posi- 
tive Wassermann. 

Thus  of  a  total  of  608  chronic  diseases  296,  or  48.6  per 
cent.,  gave  a  positive  Wassermann.  While  such  figures 
give  very  little  basis  for  deductions  as  to  prevalence  of 
syphilis,  we  may  conclude  that  as  the  percentage  in  these 
cases  is  rather  higher  than  that  expected  in  the  same  type 
of  cases  in  this  country,  it  is  a  fair  deduction  that  syphilis 
must  be  rather  more  common  in  that  part  of  France  than  in 
most  sections  of  the  United  States. 

Australia. — According  to  Barrett"  for  twelve  months 
syphilis  was  made  a  notifiable  disease  in  an  area  of  ten 
miles  radius  from  the  general  Post  Office  of  Melbourne.  No 
names  were  given,  but  the  age,  sex  and  clinical  condition 
were  certified  and  the  information  accompanied  by  a  specimen 
of  blood  for  the  Wassermann  reaction.  At  the  end  of  the 
year  about  5500  cases  had  been  reported  and  tested,  and 
3157  were  proved  to  be  syphilitic.  This  was  about  5  per  cent, 
of  the  population.  It  does  not  follow  that  this  is  the  correct 
percentage  of  syphilis  in  that  part  of  Australia,  but  it  does 
follow  that  at  least  5  per  cent,  is  definitely  known  to  be 
infected.  There  was  no  information  as  to  the  relative  prev- 
alence among  the  sexes. 

The  percentage  is  naturally  higher  among  patients  in 
hospital,  and  there  are  several  observations  bearing  on  this 
point.  Barrett^^  states  that  of  550  patients  at  various  clinics, 
44,  or  8  per  cent.,  gave  a  positive  Wassermann,  and  31,  or 
5.6  per  cent.,  gave  a  partial  Wassermann.  This  makes  a 
total  of  13.6  per  cent,  that  may  be  estimated  to  be  syphilitic 
among  this  class  of  patients.     Barrett  assumes  that  for 


STATISTICS  FROM  OTHER  COUNTRIES  41 

public  health  purposes  six  positive  Wassermanns  indicate 
the  existence  of  10  cases  of  syphilis.  Piper^^  made  a  Wasser- 
mann  survey  on  100  women  taken  in  the  order  of  admission 
to  the  women's  hospital  at  Melbourne.  There  were  10 
positive,  6  partial  and  84  negatives.  "Thus  there  is  a  result 
of  16  per  cent,  of  syphilis  definitely  present  in  a  sample  of 
100  cases  taken  at  random  from  the  class  of  female  patients 
admitted  to  a  public  hospital.  Furthermore,  as  a  negative 
Wassermann  does  not  disprove  syphilis,  no  estimate  can  be 
formed  of  the  number  of  probable  specifics  among  the  84 
whose  reaction  was  negative."  Of  these,  11  gave  a  history 
which  could  be  regarded  as  indicating  the  possibility  of 
syphilis. 

Bennie^"  believed  that  in  hospital  practice  in  Melbourne 
30  per  cent,  of  the  children  show  signs  of  syphilitic  infection, 
and  that  20  per  cent,  of  the  children  in  private  practice  are 
infected;  so  that  he  estimates  that  25  per  cent,  of  the  sick 
children  in  Melbourne  are  tainted  with  syphilis.  From  his 
knowledge  of  the  families  whom  he  has  often  treated  for 
many  years  he  believed  that  fully  14  per  cent,  of  these  families 
are  infected. 

Allen*^  published  100  consecutive  postmortems  from  hos- 
pital practice  in  which  34  showed  clear  signs  of  syphilis, 
19  others  doubtful  signs  of  syphilis  and  1  was  open  to 
suspicion.  A  second  100  consecutive  postmortems  showed 
3,2  clear  cases  and  30  others  more  or  less  doubtful.  While 
warning  against  applying  this  percentage  to  the  entire  popula- 
tion, Allen  writes:  "After  all  cautions  and  reservations  I 
am  compelled  to  hold  that  in  the  hospital  population  syphilis 
is  widespread,  a  frequent  cause  of  death  and  a  potent  factor 
of  physical  deterioration,  adding  largely  to  the  mortality 
from  many  other  diseases." 

England. — The  prevalence  of  venereal  diseases  in  Great 
Britain  has  been  a  very  live  issue  in  recent  years.  Such  a 
mass  of  evidence  has  been  presented  to  the  Royal  Commis- 
sion on  Venereal  Diseases  that  it  would  be  hopeless  to  attempt 
to  analyze  it,  and  much  of  it  is  hardly  worth  analyzing. 
In  testifying  before  this  Commission,  Dr.  French  stated 
that  in  the  British  army  the  average  number  of  cases  con- 


42        THE  PREVALENCE  OF  SYPHILIS 

stantly  on  the  syphilis  register  for  two  or  three  years  and 
undergoing  treatment  was  probably  3  or  4  per  cent.  This 
is  about  the  same  percentage  that  obtains  in  oiu-  own  army, 
and  we  know  that  the  number  thus  undergoing  treatment  is 
only  a  fraction  of  the  number  actually  infected.  A  very 
fair  estimate  was  presented  to  the  Royal  Commission  by 
Dr.  Douglas  White.^^  From  a  consideration  of  available 
statistics  in  regard  to  venereal  disease  and  making  an  attempt 
to  allow  for  differences  in  conditions,  Dr.  White  arrived 
at  the  conclusion  that  there  were  every  year  122,500  fresh 
cases  of  venereal  disease  in  London  and  800,000  fresh  cases 
in  the  United  Kingdom.  He  estimated  that  of  the  800,000 
fresh  cases,  114,000  would  be  syphilis.  From  these  figures 
he  deduced  that  there  must  be  in  the  United  Kingdom  some 
3,000,000  syphilitics,  which  would  be  something  under  7 
per  cent,  for  the  total  population.  Dr.  White  compared  the 
results  obtained  by  this  statistical  inquiry  with  the  estimate 
obtained  by  assuming  that  a  certain  percentage  of  cases  of 
syphilis  terminate  in  general  paralysis  or  locomotor  ataxia. 
The  figures  obtained  from  notification  in  Denmark  led  to 
the  conclusion  that  in  that  country  rather  less  than  2.5 
per  cent,  of  syphilitics  died  of  general  paralysis.  In  the 
United  Kingdom  there  were  about  2600  deaths  annually 
from  general  paralysis  and  about  700  deaths  from  locomotor 
ataxia.  If  it  might  be  assumed  that  3  per  cent,  of  cases  of 
syphilis  resulted  in  death  from  these  diseases  the  conclusion 
was  reached  that  there  were  about  111,000  syphilitic  infec- 
tions annually. 

Without  going  further  into  the  testimony  offered  it  should 
be  noted  that  the  conclusion  of  the  Royal  Commissions^  in 
regard  to  the  prevalence  of  venereal  diseases  in  England 
was  expressed  in  the  following  sentence:  "While  we  have 
been  unable  to  arrive  at  any  positive  figures,  the  evidence 
we  have  received  leads  us  to  the  conclusion  that  the  number 
of  persons  that  have  been  infected  with  syphilis,  acquired 
or  congenital,  cannot  fall  below  10  per  cent,  of  the  whole 
population  in  the  large  cities  and  the  percentage  infected  with 
•gonorrhea  must  greatly  exceed  this  proportion." 

Some  results  of  systematic  examination  by  means  of  the 


STATISTICS  FROM  OTHER  COUNTRIES  43 

Wassermann  reaction,  either  alone  or  in  conjunction  with 
the  clinical  examination,  are  available  and  are  of  interest. 
Mcllroy,  Watson  and  Mcllroy^^  performed  the  Wassermann 
reaction  on  100  women  in  a  Scotch  clinic  in  order  to  deter- 
mine the  prevalence  of  syphilis  among  gynecological  patients. 
All  suffered  from  a  definite  gynecological  complaint,  but  only 
six  patients  gave  a  history  pointing  to  syphilitic  infection 
in  the  past.  All  of  these  six  had  a  positive  Wassermann. 
The  patients  attending  the  clinic  are  drawn  from  the  respect- 
able working  classes,  all  cases  of  ob\dous  syphilis  being 
excluded  and  sent  elsewhere  for  treatment.  The  results 
obtained  were  very  remarkable,  for  out  of  the  100  cases 
examined,  43  (34  married  and  9  unmarried)  gave  a  positive 
Wassermann;  48,  all  married,  were  negative;  and  9  also 
married  gave  a  partial  reaction.  The  method  used  was  that 
described  by  Browning,  Cruikshank  and  Mackenzie.  This 
investigation  is  only  a  small  series,  but  so  far  as  it  goes  it 
indicates  an  amazing  prevalence  of  latent  s;^^hilis  among 
the  gynecological  patients  of  the  working  classes. 

Dr.  Ivy  Mackenzie^^  examined  the  blood  of  786  insane 
patients  in  Scotland.  Of  that  number  234  were  supposed 
from  the  clinical  examination  to  be  general  paralytics,  and 
of  these  221  gave  a  positive  Wassermann  reaction. 
Altogether,  of  the  786  cases  347,  or  44.1  per  cent.,  gave  a 
positive  reaction.  A  systematic  examination  of  the  patients 
admitted  to  his  wards  at  the  Victoria  Infirmary  showed  that 
15  per  cent,  gave  evidence  of  syphilis. 

Manson  and  Smith^^  investigated  the  prevalence  of  syphilis 
in  ocular  diseases.  Using  the  Wassermann  reaction  they 
studied  250  cases,  including  a  great  variety  of  clinical  condi- 
tions of  the  eye:  125,  or-  50  per  cent.,  were  positive,  3  w^ere 
doubtful  and  122  were  negative.  Excluding  such  conditions 
as  ocular  injuries,  conjunctivitis,  cataract  and  the  ordinary 
errors  of  refraction,  much  more  than  50  per  cent,  were 
associated  with  a  positive  reaction. 

Elliott^^  performed  a  Wassermann  reaction  on  130  children 
of  the  city  of  Glasgow,  selected  because  of  their  unhealthiness 
or  because  they  belonged  to  the  poorer  classes;  14,  or  10.8 
per  cent.,  had  a  definitely  positive  Wassermann;  4  of  these 


44  THE  PREVALENCE  OF  SYPHILIS 

cases  had  definite  signs  of  congenital  s\"philis.  If  these  cases 
were  excluded  the  percentage  of  positive  reactions  becomes 
approximately  8.5.  Elliott  concludes  that  about  8  per  cent, 
of  all  children  of  the  poorer  classes  in  Glasgow  are  syphilitic. 

Browning*^  investigated  over  3000  cases  from  different 
groups  in  the  community  by  clinical  and  serological  methods. 
Some  of  his  findings  are  as  follows: 

Children. — Among  331  cases  representative  of  the  general 
conditions  which  lead  to  the  appearance  of  children  at  the 
outdoor  department  of  a  hospital,  10  per  cent,  are  syphilitic 
both  on  clinical  evidence  and  as  a  result  of  the  Wassermann 
test;  22  per  cent,  have  a  syphilitic  association  on  clinical 
grounds,  with  confirmatory  evidence  from  a  doubtful  result 
of  the  Wassermann  test  in  4  per  cent.  This  gives  practically 
conclusive  evidence  of  syphilis  in  14  per  cent,  of  the  children 
studied.  Of  204  cases  of  mental  deficiency  and  epilepsy  in 
young  subjects,  95,  or  46  per  cent.,  had  a  positive  Wasser- 
mann. Of  25  cases  of  heart  disease  in  children,  17,  or  64 
per  cent.,  were  positive.  Of  52  cases  of  ozena  that  showed  no 
clinical  signs  of  syphilis,  and  in  which  no  syphilitic  history 
was  obtainable,  16,  or  30  per  cent.,  gave  a  positive  Wasser- 
mann. Of  46  cases  of  aortic  disease  examined,  64  per  cent, 
had  a  positive  Wassermann.  Of  122  cases  of  nervous  disease 
from  a  general  hospital,  41  per  cent,  were  positive.  Of  104 
prostitutes  examined  ranging  in  age  from  fourteen  to  eighteen 
years,  all,  or  100  per  cent.,  were  positive.  Browning  made 
no  attempt  to  gauge  the  prevalence  of  syphilis  in  the  general 
population,  but  states  that  it  is  impossible  to  avoid  the 
conclusion  that  syphilis  is  very  largely  associated  with  the 
hospitalized  portion  of  the  community,  and  also  with  certain 
classes  peculiarly  liable  to  spread  the  disease. 

Assinder^^  performed  the  Wassermann  reaction  on  500 
patients  admitted  to  the  Infirmary,  Dudley  Road,  Birming- 
ham. Of  the  500  patients  tested,  120,  or  24  per  cent.,  gave 
a  positive  reaction:  67  of  these  cases  were  obviously  luetic, 
and  if  this  number  be  subtracted  from  the  total  number  of 
patients,  it  will  be  seen  that  of  433  cases,  63,  or  14.5  per  cent., 
gave  a  positive  reaction.  In  regard  to  sex,  272  were  males 
and  80,  or  29.4  per  cent.,  gave  a  positive  reaction;  288  were 


STATISTICS  FROM  OTHER  COUNTRIES  45 

females,  of  whom  40,  or  17.5  per  cent.,  gave  a  positive 
reaction.    These  were  all  cases  belonging  to  the  poorer  classes. 

Dr.  Fildes  reported  the  results  of  1002  Wassermann  reac- 
tions made  at  the  London  Hospital.  The  patients  tested 
were  nineteen  years  of  age  and  upward  and  had  come  to 
the  hospital  for  reasons  wholly  unconnected  with  syphilis. 
Cases  of  obvious  or  probable  syphilis  were  excluded.  Of 
616  males  thus  tested,  64,  or  10.3  per  cent.,  were  positive, 
while  of  386  females,  20,  or  5.1  per  cent.,  proved  syphilitic. 
"This  implies  that  in  a  typical  working-class  population  of 
London  at  least  8  to  12  per  cent,  of  adult  males  and  at  least 
3  to  7  per  cent,  of  adult  females  have  acquired  syphilis.  If 
congenital  syphilis  were  included,  or  if  the  total  number  of 
patients  attending  had  been  tested,  the  proportion  would 
certainly  have  been  higher." 

Sir  John  Collie  carried  out  an  investigation  among 
employees  referred  for  a  medical  examination.  The  persons 
examined  fell  into  three  classes: 

1.  1119  disabled  by  accident  or  illness. 

2.  557  apparently  in  perfect  health  but  requiring  examina- 
tion before  appointment. 

3.  500  of  the  same  who  submitted  to  the  Wassermann 
test. 

The  first  two  classes  only  underwent  a  clinical  examina- 
tion; they  showed  56  cases  of  syphilis,  or  3.3  per  cent.  Among 
the  last  group  who  had  a  Wassermann,  46,  or  9.36  per  cent., 
proved  to  be  syphilitic* 

Darling^''  examined  the  blood  of  171  women  admitted  to 
the  Belfast  Maternity  Hospital  for  pregnancy  at  term.  The 
women  were  almost  all  married,  of  the  artisan  class,  and 
were  examined  in  the  order  of  admission,  making  no  selection 
in  cases;  12.8  per  cent,  gave  a  positive  Wassermann. 

She  also  quotes  the  series  of  Dr.  Mott  on  1483  patients 
admitted  to  the  infirmaries  of  Shoreditch,  Westminster  and 
Paddington,  which  gave  practically  20  per  cent,  of  positive 
reactions.  Mott  also  examined  71  mothers  in  the  Shoreditch 
Infirmary  and  obtained  14.3  per  cent,  of  positives  among 

*  Synopsis  Final  Report  of  Royal  Commission  on  Venereal  Diseases. 


46        THE  PREVALENCE  OF  SYPHILIS 

the  married  and  27.6  per  cent,  of  positive  reactions  among 
the  unmarried. 

Canada. — Dr.  Charles  K.  Clarke/^  superintendent  of  the 
Toronto  General  Hospital,  has  stated  that  since  October  6, 
1916,  routine  Wassermann  tests  have  been  done  in  the 
wards  of  the  Toronto  General  Hospital,  and  out  of  971  tests, 
125  were  positive,  a  percentage  of  12.8.  Dr.  Clarke  con- 
cludes that  more  than  12  per  cent,  of  the  patients  admitted 
to  the  public  wards  of  that  hospital  for  various  conditions, 
both  medical  and  surgical,  have  syphilis,  and  that  this  dis- 
ease must  be  considered  a  greater  menace  than  tuberculosis. 

Graham,^2  [^  ^  discussion  before  the  Toronto  Academy 
of  Medicine  stated  that  of  412  medical  cases  admitted  to  the 
Toronto  General  Hospital  the  Wassermann  reaction  was 
positive  in  180,  or  43.6  per  cent.  These  were  consecutive 
cases  admitted  between  August  11  and  December  13,  1913. 
Among  the  professional  class,  however,  the  percentage  of 
positive  reactions  was  only  7,  and  among  the  business  class 
it  was  23  per  cent. 

STATISTICS  FROM  DIFFERENT  GROUPS  IN  THE  UNITED 

STATES. 

A  few  random  quotations  indicating  various  opinions  in 
regard  to  the  prevalence  of  syphilis  may  be  of  some  interest 
as  a  prelude  to  more  serious  investigations. 

Gerrish^^  is  of  the  opinion  that  syphilis  is  one  of  the  com- 
monest diseases.  While  its  prevalence  cannot  be  precisely 
determined,  those  best  able  to  judge  declare  their  belief 
that  10  per  cent,  of  the  community  are  affected  by  it. 
Fischer^^  estimates  that  18  per  cent,  of  the  population  suffers 
from  syphilis  and  that  250,000  deaths  occur  each  year  as 
the  result  of  venereal  diseases.  Cunningham^^  wrote,  in 
point  of  prevalence,  that  syphilis  and  gonorrhea  vastly 
overshadow  all  other  infectious  diseases,  both  acute  and 
chronic.  It  is  a  conservative  estimate  that  fully  one-eighth 
of  all  human  diseases  and  suffering  comes  from  this  source. 
It  is  a  fact  worthy  of  consideration  that  every  year  in  this 
country  770,000  males  reach  the  a;ge  of  early  maturity.    It 


STATISTICS  FROM  DIFFERENT  GROUPS  47 

may  be  affirmed  that  under  existing  conditions  at  least  60 
per  cent.,  or  over  450,000,  of  these  young  men  will  some  time 
during  life  become  infected  with  venereal  disease:  20  per 
cent,  will  occur  before  the  twenty-second  year,  50  per  cent, 
before  the  twenty-fifth  year  and  80  per  cent,  before  the 
thirtieth  year.  This  is  the  venereal  morbidity  of  the  male 
product  of  a  single  year. 

It  has  already  been  pointed  out  that  accurate  figures  in 
regard  to  the  prevalence  of  syphilis  in  the  general  population 
are  not  only  unobtainable,  but  that  much  more  definite 
information  is  obtained  by  studying  the  prevalence  of  the 
disease  in  certain  groups.  In  presenting  the  evidence  with 
regard  to  the  prevalence  of  syphilis  in  the  United  States,  the 
plan  will  therefore  be  to  select  certain  definite  groups  with 
regard  to  which  more  or  less  accurate  information  is  available. 

Prostitutes. — The  percentage  of  syphilis  among  prostitutes 
might  be  expected  to  be  very  high.  Obviously  the  exact 
percentage  found  would  depend  upon  the  length  of  time  those 
examined  have  followed  their  calling,  and  upon  other  factors. 
It  may  be  supposed  that  after  several  years  of  this  life  every 
woman  would  become  infected,  and  that  such  is  not  far  from 
the  case  is  indicated  by  the  findings  of  Browning,  already 
quoted.  Among  the  older  women,  however,  the  disease 
often  becomes  latent,  especially  if  a  certain  amount  of  treat- 
ment has  been  received.  As  a  matter  of  fact,  therefore,  per- 
centages are  apt  to  be  higher  among  the  younger  women, 
since  the  old  latent  cases  may  escape  both  clinical  and  sero- 
logical methods  of  examination.  Average  figures  are  prob- 
ably given  by  Kneeland/'^  who  says  that  the  records  of  the 
Bedford  Reformatory  for  girls  show  that  20.56  per  cent,  of 
the  647  inmates  have  clinical  manifestations  of  venereal 
disease.  With  the  Wassermann  test,  224,  or  48  per  cent., 
have  positive  reactions,  and  30,  or  6.4  per  cent.,  gave  doubt- 
ful reactions.  The  same  sera  were  tested  by  the  complement- 
fixation  test  for  gonorrhea,  with  the  result  that  306,  or  65 
per  cent.,  gave  positive  reactions,  101,  or  21.7  per  cent., 
gave  doubtful  reactions,  and  59,  or  12  per  cent.,  gave  nega- 
tive reactions.  The  value  of  the  complement-fixation  test 
for    gonorrhea    is    not    yet    thoroughly   established.      But, 


48        THE  PREVALENCE  OF  SYPHILIS 

accepting  the  results  as  indicating  gonorrhea  and  syphiHs, 
the  full  significance  of  these  results  is  apparent.  Of  the  466 
girls  tested  only  50,  or  10.7  per  cent.,  were  found  to  be  free 
from  venereal  infection:  54.4  per  cent,  had  a  positive  or 
doubtful  Wassermann  and  were  probably  syphilitic,  86.7 
per  cent,  probably  suffered  from  gonorrhea  and  170,  or 
36.4  per  cent.,  gave  positive  reactions  for  both  syphilis  and 
gonorrhea.  The  complement-fixation  tests  in  these  cases 
were  made  by  Dr.  McNeil,  of  the  Research  Laboratory, 
Department  of  Health,  New  York. 

In  a  later  statement,  Davis^^  says  that  51  per  cent,  of  the 
inmates  of  this  reformatory  are  syphilitic.  Walker,  ^^  in  an 
examination  of  327  prostitutes  in  Baltimore,  found  that  67 
per  cent,  gave  a  positive  Wassermann  reaction. 

Sullivan  and  Spaulding^^  find  that  among  63  women 
arrested  for  alcoholism  only,  syphilis  was  found  in  42.8  per 
cent.,  while  9.6  per  cent,  more  show  a  doubtful  Wassermann. 
Among  94  women  arrested  for  alcoholism  and  other  offences, 
syphilis  was  found  in  46.8  per  cent.,  with  14.9  per  cent,  more 
showing  a  doubtful  Wassermann.  Among  243  prostitutes 
s;\q3hilis  was  found  in  65.5  per  cent.,  with  9.5  per  cent,  more 
showing  a  doubtful  Wassermann.  Among  the  entire  500 
consecutive  cases  who  were  all  regular  or  irregular  prostitutes, 
75.7  per  cent,  had  gonorrhea,  and  44.7  per  cent,  were  un- 
doubtedly syphilitic,  while  9.5  per  cent,  more  had  a  doubtful 
Wassermann. 

For  the  purpose  of  comparison  the  following  figures 
obtained  in  foreign  cities  may  be  quoted.  Meirowsky^^ 
examined  100  prostitutes  in  Cologne,  using  the  Wassermann 
reaction  in  conjunction  with  the  clinical  findings :  74  per  cent, 
were  found  to  be  syphilitic,  although  43  cases  were  clinically 
negative;  26  of  these  gave  a  positive  Wassermann.  Hecht^° 
examined  260  prostitutes,  also  using  the  Wassermann 
reaction.  Of  these  cases  191,  or  73  per  cent.,  had  clinical 
signs  of  syphilis,  and  49  of  these  had  received  treatment  for 
the  disease.  Of  the  total  260,  102,  or  39.2  per  cent.,  gave  a 
positive  Wassermann,  while  195,  or  75  per  cent.,  were  posi- 
tive either  clinically  or  by  the  Wassermann,  or  both.  Hecht 
observes  that  these  findings  strongly  indicate  that  almost 


STATISTICS  FROM  DIFFERENT  GROUPS  49 

all  prostitutes  that  have  followed  their  occupation  for  several 
years  must  be  infected.  While  many  of  these  cases  were 
hospital  cases,  yet  they  were  examined  in  rotation  without 
regard  to  the  cause  of  admission,  and  69  of  the  260  had  no 
clinical  evidences  of  syphilis.  Somewhat  lower  figures  have 
been  obtained  by  Swedish  investigators.  According  to 
Johansson  69  per  cent,  of  the  inscribed  women  examined 
were  syphilitic,  but  only  31  per  cent,  showed  clinical  signs  of 
the  disease.  Other  observers  are  quoted  who  found  from 
32  to  36  per  cent.,  and  Almkvist''^  out  of  32  prostitutes 
obtained  a  positive  Wassermann  in  8,  or  25  per  cent. 

Pinkus^2  stated  in  1912  that  non-syphilitic  prostitutes 
must  be  extraordinarily  rare  in  Berlin  and  that  the  majority 
acquire  syphilis  during  their  first  year.  Pinkus  examined 
by  the  Wassermann  reaction  230  of  the  older  girls  that  had 
no  history  of  syphilis  and  no  physical  signs  of  the  disease, 
and  180,  or  78.2  per  cent.,  were  positive,  while  among  the 
50  that  were  negative  some  of  them  later  had  symptoms  of 
syphilis.  Of  177  women  who  had  remained  for  ten  years 
without  history  or  symptoms  of  infection  the  Wassermann 
reaction  showed  101,  or  81.2  per  cent.,  to  be  positive. 

Excluding  the  occupation  of  prostitution  which  necessarily 
renders  those  engaged  in  it  especially  liable  to  infection  with 
syphilis,  some  classification  of  the  population  must  be  used 
to  divide  it  into  groups  that  can  be  studied.  Whites  and 
negroes  should,  of  course,  be  considered  separately.  It  then 
becomes  more  or  less  natural  to  classify  both  races  into  those 
who  are  well  and  those  who  are  sick  and  defective.  Not 
only  do  patients  who  suffer  from  manifestations  of  syphilis 
naturally  gravitate  to  hospitals  and  dispensaries,  but  these 
institutions  have  also  many  other  patients  suffering  from 
conditions  that  are  aggravated  even  if  not  caused  by  a  pre- 
existing syphilitic  infection.  Under  these  circumstances  it 
is  natural  to  expect  that  the  percentage  of  infections  among 
the  hospitalized  portion  of  the  community  will  be  higher 
than  among  those  individuals  that  are  presumably  well. 
One  of  the  first  classes  of  the  sick  to  invite  attention  is  the  insane . 

The    Insane.— Matson,«3   ^j^q    applied    the    Wassermann 
reaction  in  the  study  of  the  insane  in  1910,  says:     "The 
4 


50        THE  PREVALENCE  OF  SYPHILIS 

importance  of  syphilis  in  the  psychic  inJBrmities  is  indicated 
by  our  examination  of  470  inmates  of  the  Oregon  State 
Insane  Asylum.  Nearly  20  per  cent,  gave  positive  reactions 
while  only  5  per  cent,  gave  specific  histories,  and  none 
presented  visible  or  clinical  manifestations.  .  .  .  Nearly 
15  per  cent,  of  51  cases  of  dementia  precox  were  positive, 
while  none  gave  a  syphilitic  history:  16  per  cent,  of  151  cases 
of  paranoia  were  positive.  Twenty-five  per  cent,  of  40  cases 
of  chronic  mania  were  positive,  20  per  cent,  of  26  cases  of 
chronic  melancholia  were  positive  and  20  per  cent,  of  62 
cases  of  dementia  were  positive." 

Paine,^*  in  1912,  examined  200  consecutive  admissions  to 
the  Danvers  State  Hospital  in  Massachusetts.  The  Wasser- 
mann  was  done  in  every  case,  and  when  a  positive  or  doubtful 
report  was  received  a  spinal  puncture  was  also  performed: 
49  of  these  cases,  or  24.5  per  cent,  of  the  admissions,  showed  a 
positive  Wassermann  in  the  blood;  146  of  these  cases  were 
from  cities,  of  whom  36,  or  24.7  per  cent.,  were  positive  and 
54  cases  were  from  small  towns,  of  whom  13,  or  24.07  per 
.cent.,  were  positive;  82  cases  were  females,  of  whom  19, 
or  23.1  per  cent.,  were  positive.  The  seacoast  cities  gave 
a  percentage  of  32,  the  inland  towns  a  percentage  of  17,  the 
mill  cities  a  percentage  of  28  and  other  cities  a  percentage 
of  19.  While  these  figures  are  very  suggestive  as  to  the  dis- 
tribution of  syphilis  in  the  different  portions  of  the  State, 
the  number  of  cases  studied  is  too  small  to  form  the  basis 
of  serious  conclusions. 

Darling  and  Newcomb^^  obtained  a  Wassermann  reaction 
on  849  cases  at  the  Warren  State  Hospital,  of  which  43  cases 
were  positive,  a  percentage  of  5.06.  They  also  state:  "In 
the  seventeen  months  elapsing  since  September,  1912,  there 
were  made  as  a  routine  procedure  upon  admissions  452 
Wassermann  reactions,  of  which  92  were  positive,  giving  a 
percentage  of  20.4."  The  low  rate  of  5.06  was  for  long 
resident  chronic  insane  cases  and  contained  very  few  cases 
of  paresis,  which  are  usually  well  advanced  when  committed 
to  this  institution,  and  their  hospital  residence  is  brief. 
Among  the  new  admissions  the  high  rate  (20.4  per  cent.)  was 
due  to  cases  of  paresis  and  cerebral  lues. 


STATISTICS  FROM  DIFFERENT  GROUPS 


51 


Mitchell^^  states  in  regard  to  this  same  survey  that  18.5 
per  cent,  of  the  female  admissions  showed  a  positive  serum, 
while  22.3  per  cent,  of  the  males  gave  the  same  result. 

Southard"^  gives  figures  for  Massachusetts.  In  the 
Psychopathic  Hospital  1671  random  tests  were  made  on 
different  cases,  of  which  264  gave  a  positive  Wassermann. 
This  is  a  percentage  of  15.8  for  the  psychopathic  intake,  and 
Southard  says:  "I  consider  that  there  is  no  better  set  of 
data  available  for  Massachusetts." 

Vedder  and  Hough"^^  made  a  study  of  1283  inmates  of  the 
Government  Hospital  for  the  Insane,  Washington,  D.  C.  The 
results  of  this  examination  are  shown  in  the  following  tables : 

RESULTS  OF  WASSERMANNS  IN  SIX  HUNDRED  AND  SIXTEEN 
CONSECUTIVE   CASES. 


o 

1 

X 

B 

"ft 

1 
o 
Q 

1 

Negative 
Wassermann. 

Total  syphilitic, 
co\mting  all  but 
=•=  Wassermanns. 

.2 

Xi  g 

6 

o  o 

a 

O   m 

No. 

Per  cent. 

White  males 
White  females    . 
Colored  males   . 
Colored  females 

374 
83 
93 
65 

42 
0 

11 
6 

4 
0 

2 
1 

3 
0 

4 

1 

11 
0 
1 
0 

4 
0 

1 
1 

5* 
0 
0 
0 

7 
0 
7 
0 

73 
0 

22 
8 

19.51 

0 
23.65 
12.30 

Total  .... 

616t 

59 

7 

8 

12 

6 

5 

14 

103 

16.72 

RESULTS  OF  WASSERMANNS  IN  SIX  HUNDRED  AND  SIXTY-SEVEN 
RANDOM   CASES. 


Double  plus. 

Plus. 

Plus-minus. 

Minus. 

No. 

Per 
cent. 

No. 

Per 
cent. 

No. 

Per 
cent. 

No. 

Per 

cent. 

Hough 
Vedder 

235 
432 

17 
30 

7.23 
6.94 

5 

58 

2.12 
13.42 

5 
96 

2.12 
22.22 

208 
248 

88.51 
57.40 

Total     . 

667 

47 

7.04 

63 

9.44 

101 

15.14 

456 

68.36 

*  All  of  these  cases  had  a  positive  Noguchi  test  for  protein;  the  cell  counts 
were  respectively  9,  20,  120,  88,  160. 
t  One  Indian  is  included  in  this  total. 


52  THE  PREVALENCE  OF  SYPHILIS 

The  authors  concluded  that  among  the  white  males  the 
presence  of  syphilis  was  demonstrated  in  20  per  cent,  of  the 
cases,  that  at  least  30  per  cent,  are  probably  syphilitic  and 
that  at  least  10  per  cent,  of  the  insanity  in  this  institution 
is  directly  attributable  to  syphilis.  No  syphilis  was  detected 
among  the  83  white  females  studied,  but  this  number  is  so 
small  that  no  deductions  can  be  safely  drawn  from  it  except 
that  the  prevalence  of  syphilis  among  this  group  of  insane 
females  is  less  than  among  insane  males.  The  statistics 
obtained  for  the  colored  race  should  be  compared  with  those 
given  later  by  Ivey  under  the  figures  given  for  the  negro  race. 

More  than  one-eighth  of  the  cases  of  insanity  annually 
admitted  to  Michigan  State  hospitals  for  the  insane  are 
directly  caused  by  syphilis.  In  the  year  1913-1914,  insanity 
resulting  from  syphilis  constituted  12.9  per  cent,  of  all  cases 
admitted  to  these  hospitals.  Syphilis  was  the  direct  cause 
of  insanity  in  17.5  per  cent,  of  all  males  and  in  6.65  per  cent, 
of  all  females  admitted.  In  order  to  ascertain  the  general 
prevalence  of  syphilis  among  the  insane  in  the  Michigan 
State  hospitals  for  the  insane  the  Wassermann  test  was  made 
on  1546  patients  admitted  during  the  year  1913-1914.  In 
21.6  per  cent,  of  the  940  males  tested  positive  reactions  were 
obtained,  and  3.6  per  cent,  more  were  strongly  suggestive 
of  syphilis.  Among  the  606  females  who  were  tested,  positive 
reactions  were  obtained  in  12.7  per  cent.  Of  all  admissions 
18.1  per  cent,  gave  positive  reactions,  4.17  per  cent,  were 
questionable  and  77.2  per  cent,  were  negative. '^^ 

Holbrook^''  reported  2000  Wassermann  reactions  on  the 
1600  inmates  of  the  East  Louisiana  Hospital  for  the  Insane. 
Of  637  white  males,  50,  or  8  per  cent.,  gave  positive  reac- 
tions; 516  white  females,  20,  or  4  per  cent.,  gave  positive 
reactions;  212  colored  males,  15,  or  7  per  cent.,  gave  posi- 
tive reactions;  235  colored  females,  25,  or  11  per  cent.,  gave 
positive  reactions. 

Thus  of  1153  white  patients  6  per  cent,  gave  a  positive 
reaction,  while  of  447  negroes  9  per  cent,  gave  a  positive 
reaction.  These  figures  appear  very  low,  but  the  majority 
were  chronic  cases,  and  the  acetone-insoluble  antigen  was 
used.    A  study  of  the  515  cases  received  during  the  biennium 


STATISTICS  FROM  DIFFERENT  GROUPS  53 

ending  March,  1916,  showed  that  11.07  per  cent,  were  paretic 
and  17.4  per  cent,  were  syphilitic.  These  figures  are  prob- 
ably much  closer  to  the  facts  regarding  the  psychopathic 
intake  of  the  State  of  Louisiana,  but  even  here  it  must  be 
remembered  that  higher  figures  would  undoubtedly  have  been 
obtained  had  the  cholesterinized  antigen  been  used. 

FelP^  examined  1700  consecutive  admissions  to  the  Elgin 
State  Hospital  of  Illinois  and  found  that  16  per  cent,  of  the 
admissions  were  syphilitic,  or  about  22  per  cent,  of  the  males 
and  9.5  per  cent,  of  the  females.  Paresis  formed  about  12 
per  cent,  of  the  admission  rate,  being  19  per  cent,  for  males 
and  5.5  per  cent,  for  the  females.  The  Wassermann  reaction 
was  used  in  this  work  in  conjunction  with  the  clinical  findings. 

Percentages  of  Syphilis  among  Patients  in  Hospitals  and 
Dispensaries. — Most  of  the  hospitals  and  dispensaries  from 
which  information  of  this  character  can  be  obtained  are 
located  in  the  cities.  Evidence  from  cities  in  various  parts 
of  the  United  States  will  be  presented. 

New  York. — Kneeland*^  states  that  during  the  year  1911, 
522,722  cases  of  all  kinds  were  treated  in  17  dispensaries  in 
New  York,  of  whom  15,781  were  venereally  affected.  Of 
5380  cases  treated  in  13  hospitals,  6.33  per  cent,  were 
venereally  affected.  These  figures  are  far  from  showing  the 
actual  extent  of  syphilitic  infection.  As  soon  as  the  Wasser- 
mann reaction  is  applied  the  percentages  increase.  Thus 
of  308  adults  admitted  to  the  medical  wards  of  a  New  York 
hospital  during  three  months  in  1913  the  Wassermann  was 
applied  in  166  cases,  of  which  38,  or  23  per  cent.,  gave  positive 
results.  This  is  equivalent  to  12.3  per  cent,  of  the  entire 
308,  but  had  the  test  been  applied  to  all  admissions  the 
figures  would  undoubtedly  have  been  higher. 

Greeley'^"  reports  that  fully  20  per  cent,  of  the  general 
patrons  of  hospitals  during  the  past  few  years  and  over  8  per 
cent,  of  the  peddlers  recently  examined  in  New  York  City 
by  the  Department  of  Health  gave  positive  Wassermann 
tests,  and  for  other  reasons,  fully  10  per  cent,  of  the  general 
population  can  be  conservatively  regarded  as  having  at  some 
time  or  other  suffered  from  syphilis. 

Dr.  Haven  Emerson  very  kindly  sent  me  the  following 


54        THE  PREVALENCE  OF  SYPHILIS 

additional  data  from  the  New  York  Department  of  Health : 
In  1915  routine  tests  were  made  on  110  masseurs  and  12 
were  found  to  give  a  positive  Wassermann  reaction.  During 
1915  and  1916  the  physicians  attached  to  the  occupational 
clinic  examined  a  total  of  70,714  persons,  and  the  Wassermann 
test  was  used  in  2982  of  these  cases.  In  about  20  per  cent, 
of  the  cases  the  Wassermann  was  used  because  of  some  sus- 
picious circumstance  in  the  history  or  clinical  examination, 
but  in  the  remainder  of  the  cases  the  Wassermann  was  taken 
as  a  routine  measure,  for  the  most  part  in  persons  who 
denied  all  history  of  syphilis.  Of  the  2982  cases  in  which  the 
reaction  was  performed  there  were  657,  or  22  per  cent.,  of 
positive  reactions.  The  persons  so  examined  were  bakers, 
peddlers,  food-handlers  and  certain  other  special  trade 
groups.  It  is  difficult  to  form  any  conclusions  as  to  the  prev- 
alence of  syphilis  among  these  workers  from  these  figures. 
One-fifth  of  these  examinations  were  made  in  selected  cases 
suspected  of  syphilis.  If  we  assume  that  because  of  this 
selection  these  figures  are  a  fifth  too  high,  then  the  actual 
prevalence  of  syphilis  among  this  group  would  be  four-fifths 
of  the  above  figures,  or  525  cases,  17.6  per  cent,  of  the  2982 
cases  examined.  This  figure  is  not  very  different  from  the 
estimate  made  by  Vedder  in  regard  to  the  prevalence  of 
syphilis  among  the  class  from  which  the  army  is  recruited 
(20  per  cent.). 

Bulkley^^  in  20,000  of  his  personal  dermatological  cases 
found  syphilis  in  over  12  per  cent.,  while  in  300,000  cases 
compiled  by  members  of  the  American  Dermatological  Asso- 
ciation, syphilis  was  found  as  a  causative  factor  in  about 
11  per  cent,  of  the  cases. 

Symmers^^  wrote  that  the  Wassermann  reaction  in  Bellevue 
Hospital  has  yielded  strongly  positive  results  in  over  25  per 
cent,  of  the  enormous  number  of  serums  examined.  Many, 
though  not  all  of  these,  were  consecutive  random  examinations. 
On  the  other  hand,  among  4880  necropsies  performed  at 
Bellevue  Hospital  in  the  past  ten  years,  anatomical  confirma- 
tion of  the  existence  of  syphilis  was  found  in  only  314  cases, 
or  6.5  per  cent. 

Through  the  kindness  of  Dr.  William  F.  Snow  I  have  been 


STATISTICS  FROM  DIFFERENT  GROUPS 


55 


able  to  secure  a  tabulation  of  the  Wassermann  reactions 
performed  at  Bellevue.  The  results  for  the  year  1915  were 
selected  because  it  was  the  year  when  routine  tests  were  very 
largely  made.  The  Wassermann  reactions  here  recorded 
were  performed  by  Dr.  Cyrus  W.  Field.  Fixation  of  the 
complement  was  on  an  18-unit  basis,  and  in  the  following 
tabulation  fixation  of  0  to  3  units  was  considered  negative, 
3  to  8  units  a  partial  reaction  and  8  to  18  units  a  positive 
reaction. 

The  work  of  tabulating  these  results  was  performed  by 
Miss  Sarah  Greenspan  at  the  request  of  Dr.  Snow.  I  wish 
to  express  my  indebtedness  to  both  Dr.  Snow  and  Miss 
Greenspan  both  for  obtaining  these  results  and  for  permitting 
me  to  use  them. 


Cases. 

Positive. 

Partial. 

Negative. 

Service. 

No. 

Per 
cent. 

No. 

Per 
cent. 

No. 

Per 
cent. 

Men's  medical 
Men's  surgical 

3012 
1073 

861 
245 

28.5 
22.8 

170 
56 

6.57 
5.2 

1981 

772 

65.7 
71.9 

Total  males 

4085 

1106 

27.0 

226 

5.5 

2753 

67.4 

Women's  medical 
Women's  surgical 
Women,  pregnancy    . 

1178 
574 
699 

341 

134 

97 

28.9 
23.3 
13.8 

91 
35 
46 

7.7 
6.1 
6.5 

746 
405 
556 

63.3 
70.5 
79.5 

Total  women    . 

2451 

572 

23.3 

172 

7.0 

1707 

69.3 

Children,  male 
Children,  female  . 

116 
75 

22 
20 

18.9 
26.6 

13 
5 

11.2 
6.6 

81 
50 

69.8 
66.6 

Total  children  . 

191 

42 

21.9 

18 

9.4 

131 

68.5 

Syphilis,  male 
Syphilis,  female    . 
Syphilis,  children,  male    . 
Syphilis,  children,  female 

2156 

888 
73 
47 

885 

378 

23 

17 

41.0 
42.5 
31.5 
36.2 

145 
61 

7 
4 

6.7 
6.9 
9.6 

8.5 

1126 

449 

43 

26 

52.2 
50.5 
58.8 
55.3 

Total  syphilis   . 

3164 

1303 

41.1 

217 

6.8 

1644 

51.9 

Total  all  cases 

9891 

3023 

30.5 

633 

6.4 

6235 

62.8 

56  THE  PREVALENCE  OF  SYPHILIS 

In  interpreting  these  results  it  should  be  noted  that  the 
cases  listed  in  the  men's  and  women's  medical  and  surgical 
wards  were  taken  as  a  routine.  In  the  case  of  women 
admitted  for  pregnancy,  specimens  were  not  taken  as  a 
routine  in  all  cases,  but  were  partly  routine  and  partly  on 
women  who  were  suspected  of  being  syphilitic  or  whose 
infants  had  suspicious  symptoms.  It  must  also  be  noted 
that  all  the  cases  listed  under  the  heading  "Syphilis"  are 
not  necessarily  actual  cases  of  syphilis  but  are  those  cases  in 
whom  a  preliminary  diagnosis  of  syphilis  was  made,  some- 
times on  very  slight  grounds.  These  cases  are  tabulated 
under  the  heading  "Syphilis"  because  it  would  be  obviously 
unfair  to  include  these  cases  among  the  routine  cases  from 
the  medical  and  surgical  wards,  and  yet  the  percentage  of 
positive  Wassermann  reactions  in  these  cases  is  so  low  (41.1) 
that  it  is  obvious  that  many  of  them  were  not  syphilitic. 
If  all  these  cases  be  included,  then  out  of  9891  cases,  3023, 
or  30.5  per  cent.,  were  positive.  If  we  exclude  the  cases 
suspected  of  being  syphilitic,  then  out  of  a  total  of  6535 
routine  tests  on  both  men  and  women  there  were  1678,  or 
25.6  per  cent.,  of  positive  reactions.  Of  4085  males  in  the 
medical  and  surgical  wards,  1106,  or  27  per  cent.,  were  posi- 
tive, while  among  1752  females  in  the  medical  and  surgical 
wards,  475,  or  27.1  per  cent.,  were  positive.  It  is  therefore 
apparent  that  among  the  sick  women  admitted  to  this  hos- 
pital the  percentage  of  syphilis  is  no  lower  than  among  the 
sick  men.  It  is  believed  that  these  percentages  are  very 
conservative,  because  they  do  not  include  the  results  of  the 
physical  examination  or  the  partial  Wassermann  reactions, 
but  are  based  solely  on  the  positive  Wassermann  reaction; 
and  also  because  so  many  cases  of  syphilis  have  been  excluded 
among  the  cases  in  whom  a  diagnosis  of  probable  or  possible 
syphilis  was  made.  It  seems  quite  probable  that  the  actual 
percentage  of  syphilis  among  the  admissions  to  this  hospital 
is  at  least  30  and  may  very  well  be  higher. 

On  the  other  hand,  among  women  admitted  for  preg- 
nancy, and  who  are  presumably  healthy  women,  the  per- 
centage is  much  lower,  namely,  13.8  per  cent.  This  figure 
is   higher  than  that   obtained   for  pregnant  women   else- 


STATISTICS  FROM  DIFFERENT  GROUPS 


57 


where,  which  is  to  be  explained  because  the  examinations 
here  were  not  routine,  but  partly  on  suspected  cases,  and  also 
because  the  women  admitted  here  probably  belong  to  a 
poorer  and  more  ignorant  class  than  the  admissions  to  some 
of  the  other  maternity  hospitals  from  which  figures  are 
presented. 

The  higher  percentage  of  positive  reactions  obtained  among 
the  children  in  this  hospital  is  also  worthy  of  note,  but 
inasmuch  as  these  groups  are  so  small,  no  conclusions  will 
be  drawn  from  them. 

Dr.  F.  C.  Costen  has  very  kindly  sent  me  the  results  of 
the  Wassermann  reaction  as  used  in  the  Post-Graduate 
Hospital  of  New  York  for  the  calendar  year  1916.  Only 
white  patients  are  included  and  no  selection  of  cases  was 
made.  The  Wassermann  reactions  were  performed  in  the 
laboratory  of  Dr.  Ward  J.  MacNeal  and  the  reactions  are 
on  a  four-plus  basis.  I  have  interpreted  the  four-plus  and 
three-plus  reactions  as  positive  and  the  two-plus  and  one- 
plus  reactions  as  partial  reactions: 


Male. 

Female. 

Total. 

Nega- 
tive. 

+ 
and 

+  + 

+  +  + 
and 

+  +  +  + 

Per 

cent, 
posi- 
tive. 

Total. 

Nega- 
tive. 

-1- 
and 

+  + 

+  +  + 
and 

+  +  +  + 

Per 
cent, 
posi- 
tive. 

0-10.. 
11-20 . . 
21-30.. 
31-40.. 
41-50.. 
Over  50 

Ill 
140 
262 
269 
221 
165 

76 
97 
158 
145 
133 
119 

15 
13 
29 
24 
11 
16 

20 
30 

75 

100 

77 

30 

18.0 
21.4 

28.6 
37.1 
34.8 
18.1 

74 

99 

202 

182 

105 

84 

46 
54 
120 
104 
67 
65 

12 

8 

23 

26 

8 
8 

16 
37 
59 
52 
30 
11 

21.6 
37.3 
29.2 
28.6 
28.5 
13.1 

Total .  . 

1168 

728 

108 

332 

28.4 

746 

456 

85 

205 

27.4 

Of  a  total  of  1168  white  male  patients,  332,  or  28.4  per 
cent.,  gave  a  positive  Wassermann,  while  of  746  female 
white  patients,  205,  or  27.4  per  cent.,  gave  a  positive  Wasser- 
mann. From  these  figures  we  may  conclude  that  approxi- 
mately 30  per  cent,  of  the  patients  of  this  hospital  are 
syphilitic,  and,  further,  that  the  percentage  is  not  materially 


58        THE  PREVALENCE  OF  SYPHILIS 

lower  among  the  females  than  among  the  males.  The  figures 
also  indicate  that  the  percentage  of  those  infected  steadily 
increases  with  advancing  years  at  least  up  to  the  age  of  forty. 
The  sudden  decline  after  forty  is  equally  interesting.  It  is 
known  that  the  death-rate  among  syphilitics  over  forty  is 
approximately  twice  as  high  as  among  normal  individuals, 
so  that  this  affords  the  most  probable  explanation  for  the 
diminishing  morbidity  rate  after  forty.  Many  of  the  syphi- 
litics have  already  died. 

Chicago. — Gatewood^^  reported  the  results  of  1400  Wasser- 
mann  reactions  performed  in  the  Michael  Reese  Hospital 
on  all  classes  of  patients.  A  test  may  be  ordered  for  any 
patient  in  the  hospital,  and  some  of  the  physicians  order  the 
Wassermann  almost  as  a  routine.  Many  of  the  patients 
showed  no  symptoms  or  gave  no  history  of  syphilitic  infec- 
tion. Of  this  series  of  1400  tests,  400,  or  28.5  per  cent.,  were 
positive.  Since  tests  were  not  performed  on  all  admissions 
this  percentage  does  not  represent  the  percentage  of  syphilis 
in  all  admissions.  But  if  the  cases  diagnosed  as  syphilis  are 
deducted  the  remainder  of  the  tests  constitute  practically 
a  random  series.  Among  the  400  positive  reactions  there 
were  11  cases  of  primary  syphilis,  90  of  secondary  syphilis, 
43  of  tertiary  syphilis,  22  parasyphilitics  and  10  cases  of 
hereditary  syphilis,  or  a  total  of  176  cases  in  which  the  clinical 
diagnosis  of  syphilis  was  made.  Deducting  these  cases  we 
find  that  in  a  series  of  1224  random  tests,  .224,  or  18.3  per 
cent.,  were  positive.  As  the  Wassermann  reaction  does  not 
detect  all  cases  of  syphilis,  and  as  the  clinical  cases  of  syphilis 
are  deducted  from  these  figures,  the  percentage  of  syphilis 
among  patients  admitted  to  the  Michael  Reese  Hospital 
must  be  more  than  18  per  cent.,  and  may  be  conservatively 
estimated  at  20  per  cent.  Moreover  a  considerable  majority 
of  the  patients  are  Jews,  among  whom  the  incidence  of  syphilis 
is  generally  believed  to  be  lower  than  is  the  case  in  the 
gentile  population. 

Moore^^  wrote  in  1915:  "The  general  medical  dispensary 
affords  a  medium  by  which  we  come  in  contact  with  a  certain 
class  of  persons  in  whom  through  poverty,  deficient  education 
and  mental  instability  we  might  expect  a  higher  percentage 


STATISTICS  FROM  DIFFERENT  GROUPS  59 

of  syphilis  than  in  the  average  of  the  community."  Dm-ing 
several  months  Wassermann  reactions  were  made  as  a  routine 
test  on  nearly  all  persons  attending  clinics  of  the  University 
of  Illinois  College  of  Medicine.  Of  418  patients,  56,  or  13.4 
per  cent.,  reacted  positively.  Omitting  those  who  gave  a 
weak  reaction  and  had  no  history  or  symptoms  of  syphilis, 
and  adding  those  who  reacted  negatively  but  who  were  known 
to  have  had  the  disease,  there  were  78,  or  18.6  per  cent.,  of 
the  group  who  were  syphilitic.  Of  the  89  women  tested, 
16,  or  18  per  cent.,  had  a  positive  Wassermann;  while  of  the 
329  males  tested,  40,  or  12.2  per  cent.,  had  a  positive  Wasser- 
mann. The  number  of  women  tested  was  too  small  to  afford 
a  basis  for  drawing  a  comparison  between  the  males  and 
females,  but  at  least  it  can  be  said  that  the  percentage  of 
syphilitic  infections  is  probably  quite  as  high  among  this 
class  of  female  patients  as  among  the  male  patients. 

Felpi  examined  1700  consecutive  admissions  to  the  Elgin 
State  Hospital,  using  the  Wassermann  reaction  in  conjunc- 
tion with  a  physical  examination.  This  is  a  hospital  for  the 
insane,  but  it  draws  its  inmates  from  the  State  as  a  whole, 
so  that  both  urban  and  rural  districts  are  about  equally 
represented.  Sixteen  per  cent,  of  admissions  were  sj-philitic: 
22  per  cent,  of  males  and  9.5  per  cent,  of  females.  Paresis 
formed  about  12  per  cent,  of  the  admission  rate:  19  per  cent, 
of  males  and  5.5  per  cent,  of  females.  Fell  states  that  after 
deducting  the  strictly  syphilitic  psychoses  there  is  no  reason 
why  the  percentage  of  syphilitics  among  the  admissions  to 
the  State  hospital  should  differ  materially  from  that  of  the 
adult  population  at  large,  and  estimates  on  this  basis  that 
about  5  per  cent,  of  the  population  of  Illinois  is  syphilitic, 
with  men  affected  somewhat  more  frequently  than  women. 

Michigan. — Peterson"  reported  the  results  of  a  study  of 
2000  cases  admitted  to  the  hospital  of  the  University  of 
Michigan,  and  excluding  patients  admitted  to  the  depart- 
ment of  dermatology  and  syphilology  in  accordance  with  the 
purpose  of  the  investigation  which  was  to  determine  the 
prevalence  of  syphilis  among  the  average  hospital  patients. 

In  2000  patients  there  were  110  positive  Wassermann 
reactions   in    which   the   diagnosis   was   confirmed   by   the 


60  THE  PREVALENCE  OF  SYPHILIS 

department  of  syphilology.  Among  patients  giving  a  doubt- 
ful reaction  there  were  eight  who  were  subsequently  proved 
to  be  syphilitic.  This  indicates  that  at  least  6  per  cent,  of 
the  general  run  of  hospital  patients  in  this  institution  are 
syphilitic.  When  considering  this  low  figure  it  must  be  remem- 
bered that  the  obviously  syphilitic  are  excluded  from  these 
figiu-es  by  the  exclusion  of  the  department  of  syphilis.  But 
even  making  this  allowance,  these  figiu'es  seem  very  low  in  view 
of  the  findings  of  Warthin''^  in  the  same  institution.  Warthin 
found  the  Treponema  pallidum  together  with  the  pathological 
lesions  of  syphilis  in  one-third  of  the  adult  necropsies  from 
the  University  Hospital.  It  should  be  stated  that  this  is  a 
State  hospital  whose  patients  represent  the  average  middle- 
class  population  of  the  State  of  Michigan.  The  greater  part 
of  the  cases  gave  no  history  of  syphilis  and  were  ignorant 
of  the  fact  that  they  had  contracted  the  disease.  While  the 
Wassermann  reaction  may  be  open  to  some  criticism  as  an 
indication  of  syphilitic  infection,  no  such  objection  can  be 
brought  against  Warthin's  findings.  The  actual  finding 
of  the  causal  organism  by  a  master  of  technic  cannot  be 
criticised,  and  Warthin's  33  per  cent,  must  be  regarded  as 
much  nearer  the  real  truth  with  regard  to  the  prevalence  of 
this  disease  than  the  evidence  obtained  by  Wassermann 
surve^^s.  It  is  interesting,  however,  to  note  that  Peterson 
found  the  percentage  of  syphilis  in  381  cases  in  the  maternity 
department  to  be  4.7  per  cent,  as  shown  by  the  Wassermann 
reactions  and  physical  examinations. 

Boston. — Walker  and  Haller,^^  in  1916,  investigated  the 
prevalence  of  unsuspected  syphilis  among  patients  in  a 
general  hospital  by  performing  the  Wassermann  reaction  on 
4000  cases  from  the  Peter  Bent  Brigham  Hospital:  1800  of 
these  patients  were  in  the  medical  wards,  350  in  the  neuro- 
logical division  of  the  surgical  service  and  1850  were  in  the 
outdoor  department  or  in  the  general  surgical  service.  The 
original  Wassermann  technic,  with  the  substitution  of  a  0.4 
per  cent,  cholesterinized  alcoholic  human  heart  extract  for 
antigen,  was  used.  Among  the  4000  cases,  600,  or  15  per 
cent.,  gave  complete  fixation.  Only  48  of  these  600  patients 
were  in  any  early  stage  of  the  disease,  i.  e.,  13  had  a  chancre 


STATISTICS  FROM  DIFFERENT  GROUPS 


61 


and  35  had  an  early  rash.  The  remainder  were  the  class  of 
patients  that  may  be  found  in  any  general  hospital.  It  may 
be  assumed  that  had  the  partial  reactions  been  carefully 
studied  in  connection  with  the  history  and  clinical  condition 
the  percentage  of  syphilitics  would  have  been  even  higher. 

Hornon*"  applied  the  Wassermann  reaction  to  unselected 
medical  cases  of  the  Boston  City  Hospital.  Of  500  cases  so 
tested,  87,  or  17.4  per  cent.,  had  a  positive  test,  and  In  only 
18  of  these  cases  was  a  probable  diagnosis  of  syphilis  made 
before  the  Wassermann  reaction  was  received. 

Of  312  Wassermann  reactions  from  consecutive  admissions 
at  the  Boston  Marine  Hospital  from  February  to  October, 
1916,  excluding  readmissions  and  faulty  specimens,  and 
considering  doubtful  reactions  as  negative,  77,  or  24.7  per 
cent.,  were  positive.  Including  11  cases  giving  a  negative 
reaction  on  account  of  recent  treatment  the  total  incidence 
was  28.2  per  cent.^^ 

The  following  table  presents  a  resume  of  the  4218  Wasser- 
mann tests  made  by  the  laboratory  of  the  Massachusetts 
State  Department  of  Health  dm'ing  1915  upon  various 
institutional  groups: 


Classification  of  patients 

Number, 

Percentage 

examined. 

Number. 

positive. 

positive. 

Psychopathic  patients    . 

1997 

298 

14.8 

Feeble-minded  and  delinquent 

679 

61 

9.0 

Criminal  subjects      .... 

185 

74 

40.0 

Tuberculous  subjects     . 

4.32 

39 

9.0 

Cancer 

21 

1 

4.8 

Pregnant  women       .... 

172 

8 

4.7 

Infants  and  children 

136 

24 

18.5 

Acute  general  hospital  group    . 

419 

68 

16.2 

Chronic  diseases       .... 

177 

48 

26.1 

Total 


4218 


621 


15.0 


San  Francisco. — Whitney^^  classified  7885  case  histories 
from  the  out-patient  department  of  the  University  of 
California  Hospital  from  July  1,  1912,  to  WLsiy  1,  1914. 
The  Wassermann  reaction  was  used  in  part  of  these  cases, 
some  departments  requiring  a  routine  Wassermann  reaction 
and  some  only  calling  for  it  in  selected  cases.  It  will  be  seen 
from  the  follovving  table  that  6.9  per  cent,  of  the  entire  7885 


62  THE  PREVALENCE  OF  SYPHILIS 

cases  were  syphilitic,  while  of  the  363  cases  from  the  nerve 
chnic  82,  or  22.6  per  cent.,  were  syphilitic,  and  in  the  medical 
clinic  of  1695  cases,  370,  or  21.8  per  cent.,  were  syphilitic. 
It  may  fairly  be  assumed  that  had  the  Wassermann  reaction 
been  universally  employed  the  percentages  would  have  been 
higher,  and  it  is  not  improbable  that  a  survey  of  the  patients 
in  the  hospital  would  have  furnished  figures  higher  still. 

CASES    OF   SYPHILIS   IN   VARIOUS   DEPARTMENTS    OF   THE    OUT- 
PATIENT DEPARTMENT. 

Cases  of  Total  new        Percentage  of 

Department.  syphilis.  cases.  syphilis. 

Whole  O.  P.  D 544  7885  6.9 

Nerve 82  363  22.6 

Medical 370  1695  21.8 

Skin 134  892  15.0, 

Orthopedic 90  652  13.8 

Genito-urinary 57  434  12.9 

Eye 121  1421  8.5 

Throat,  nose,  ear 53  1597  3.3 

Children 26  890  2.9 

Women's  clinic 21  915  2 . 3 

Surgical 28  1262  2.2 

As  the  children's  department  is  stated  to  have  required  a 
routine  Wassermann  in  every  case  for  several  years  the 
percentage  found  (2.9)  may  be  assumed  to  be  very  close  to 
the  actual  prevalence  of  the  disease.  The  nerve  department 
also  demanded  the  reaction  in  almost  every  case  and  the 
medical  department  for  over  half  the  cases.  Nothing  was 
said  as  to  the  surgical  department,  and  it  is  a  fair  assumption 
that  the  Wassermann  reaction  was  not  used  to  any  great 
extent  by  this  department.  Had  it  been  used  as  a  routine 
test  there  is  every  reason  to  believe  that  the  figures  would 
have  been  more  like  those  obtained  by  the  medical  depart- 
ment. The  general  average  of  6.9  per  cent,  for  the  entire 
number  of  cases  must  therefore  be  taken  to  represent  the 
amount  of  syphilis  actually  found,  but  cannot  be  taken  as  an 
estimate  of  the  amount  of  syphilis  present  in  this  class  of 
cases. 

Knappi^2  reported  the  results  of  an  examination  of  400 
cases  studied  in  St.  Luke's  Hospital,  San  Francisco.     No 


STATISTICS  FROM  DIFFERENT  GROUPS  63 

selection  was  made  of  the  cases  and  the  Wassermann  reaction 
was  used  as  an  aid  in  diagnosis.  Of  177  male  patients,  41, 
or  23  per  cent.,  were  syphilitic,  while  of  223  female  patients, 
10,  or  4.4  per  cent.,  were  syphilitic.  The  work  appeared  to 
be  carefully  done,  and  while  this  is  a  small  series,  it  is  believed 
that  such  a  series  gives  a  more  accurate  idea  of  the  prevalence 
of  syphilis  in  the  hospitalized  portion  of  the  community  than 
many  larger  series  in  which  the  examination  has  not  been  so 
thorough. 

New  Jersey. — Hammond^^  examined  all  the  inmates  of  the 
New  Jersey  State  Hospital  at  Trenton,  which  is  an  institution 
whose  intake  is  representative  of  the  rural  type  of  the  general 
population  of  the  State.  In  all  1583  individuals  were  tested 
by  the  Wassermann  reaction :  70  of  these  were  cases  of  general 
paralysis  and  1513  cases  were  otherwise  diagnosed.  Of  the 
cases  not  general  paralysis,  1472  gave  negative  reactions,  and 
41,  or  2.7  per  cent.,  gave  positive  reactions. 

Including  cases  of  general  paralysis  about  7  per  cent,  of 
all  individuals  of  both  sexes  examined  and  about  10  per  cent, 
of  all  males  were  found  to  be  syphilitic.  Hammond  believed 
that  this  percentage  is  representative  of  the  entire  general 
adult  population  of  the  rural  parts  of  the  State,  because  a 
careful  analysis  of  the  data  obtained  led  to  the  conclusion 
that  syphilis  among  the  insane  is  no  more  frequent  in  occur- 
rence than  in  the  general  community.  He  concluded  that 
the  prevalence  of  lues  in  the  entire  general  adult  population 
of  the  State  of  New  Jersey  is  7  per  cent. 

It  is  not  believed  that  this  estimate  can  be  accepted 
unreservedly.  In  the  first  place  the  incidence  of  syphilis 
in  an  asylum  is  higher  than  that  in  the  general  community 
because  of  the  tendency  of  paretics  and  cases  of  cerebral  lues 
to  gravitate  to  the  asylum.  On  the  other  hand,  if  these  cases 
be  excluded  the  incidence  of  2.7  per  cent,  is  believed  to  be 
too  low  even  for  rural  sections  of  the  country.  Hammond 
believed  that  his  data  indicated  that  the  prevalence  of 
syphilis  in  city  and  country  is  in  general  exactly  two  to  one. 
Excluding  paretics  this  would  mean  that  the  incidence  of 
sj^hihs  in  cities  of  New  Jersey  would  be  5.4  per  cent.  We 
have  already  indicated  the  danger  of  making  estimates  of  this 


64  THE  PREVALENCE  OF  SYPHILIS 

character,  and  although  the  work  was  evidently  done  with 
care  the  percentage  of  positive  cases  is  very  low  as  compared 
with  the  results  obtained  by  workers  in  other  similar  asylums. 

Richmond,  Va. — Van  der  Hoof^^  reports  that  of  2449 
patients  including  white  and  colored  from  the  out-patient 
and  in-patient  clinics  of  the  Medical  College  of  Virginia, 
44  per  cent,  showed  complete  fixation,  with  an  additional  12 
per  cent.,  giving  partial  or  incomplete  reactions.  In  the 
psychopathic  clinic  of  that  college  42  per  cent,  of  incorrigible 
or  backward  children  have  a  positive  Wassermann.  The 
high  persentages  here  given  may  be  assumed  to  be  due  to 
the  inclusion  of  negroes  in  these  statistics. 

Birmingham. — McLester^^  reports  300  consecutive  private 
patients  seen  in  his  practice  and  in  consultation  with  other 
physicians.  The  original  Wassermann  reaction  was  per- 
formed by  a  competent  technician  using  the  original  technic 
and  a  beef-heart  antigen.  Of  the  300  cases,  56,  or  18.8  per 
cent.,  gave  a  positive  reaction.  Of  the  positive  cases,  22,  or 
39  per  cent.,  gave  a  history  of  syphilis,  while  34,  or  61  per 
cent.,  gave  no  such  history. 

Baltimore. — Major^^  reported  the  reactions  performed  at 
the  Johns  Hopkins  Hospital  from  September  1,  1911,  to 
August  1,  1912.  The  reaction  was  performed  on  the  sera  of 
1200  patients,  the  great  majority  of  whom  were  medical 
cases,  and  included  a  great  variety  of  diseases  from  out- 
spoken syphilis  to  neurasthenia  and  similar  cases  in  whom 
the  reaction  was  performed  to  exclude  syphilis.  The  series 
includes  functional  and  organic  nervous  diseases,  (iardiac 
diseases,  nephritis,  diabetes,  pneumonia,  t;>'phoid  fever, 
gastro-intestinal  diseases — practically  every  medical  condi- 
tion seen  in  an  active  clinic.  Therefore,  although  no  attempt 
was  made  to  take  every  admission,  the  results  cannot  be 
greatly  above  the  average  of  the  intake  of  this  medical  clinic. 
Of  the  1200  cases,  239,  or  20  per  cent.,  gave  positive  reactions, 
while  961,  or  80  per  cent.,  were  negative.  The  series  included 
185  negroes,  the  majority  being  cardiorenal  cases,  and  of 
this  number  61,  or  about  34  per  cent.,  gave  positive  reactions. 
According  to  Janeway,^^  of  1272  consecutive  white  patients 
of  this  same  medical   clinic  from  September  21,   1914,  to 


STATISTICS  FROM  DIFFERENT  GROUPS  65 

April  2,  1916,  106,  or  13  per  cent.,  had  a  positive  Wassermann 
reaction,  while  of  288  colored  individuals  examined  during  the 
same  period,  124,  or  43  per  cent.,  had  a  positive  Wassermann. 
As  this  series  consists  of  consecutive  cases  it  gives  an  excellent 
picture  of  the  prevalence  of  syphilis  among  medical  patients 
attending  hospitals  and  dispensaries  in  Baltimore. 

Walker^^  reported  in  1916  that  in  a  recent  examination 
of  1080  patients,  regardless  of  the  disease  for  which  they 
sought  treatment,  10.8  per  cent,  gave  a  positive  Wassermann. 

Philadelphia. — ^According  to  Krumbhaar  and  Mont- 
gomery,^^ of  1000  consecutive  new  cases  at  the  Pennsylvania 
Hospital  Dispensary,  34  were  diagnosed  as  luetic  and  30 
of  these  gave  positive  Wassermann  reactions.  They  state 
that  this  3  per  cent,  of  all  dispensary  cases  is  probably  below 
half  of  the  actual  proportion  of  syphilitic  patients  attending 
the  clinic  and  indicate  only  those  patients  having  conditions 
obviously  syphilitic.  A  routine  Wassermann  reaction  on 
the  entire  number  would  have  given  much  higher  figures.   . 

The  following  figures  are  given  by  Rosenberger,^"  com- 
prising the  Wassermann  reactions  performed  during  1916  at 
the  Philadelphia  General  Hospital.  It  is  not  claimed  that 
all  patients  are  included,  so  that  it  must  be  assumed  that  the 
Wassermann  reaction  is  only  performed  on  selected  cases. 

Ward.                                Positive.  Negative.  Total. 

Men's  medical 259  838  1097 

Psychopathic .198  708  906 

Insane 154  407  561 

Men's  and  women's  nervous    .      .  103  329  432 

Men's  and  women's  surgical     .      .  92  181  273 

Women's  medical 103  170  273 

Men's  and  women's  tuberculosis   .  98  193  291 

Maternity 10  126  136 

Women's  venereal 127  151  278 

Gynecological      ......  20  49  69 

Children's 8  48  56 

Men's  venereal 45  13  58 

Total 1217  or  27.4  per  cent,  of   4430 

Dr.  John  H.  Musser,  Jr.,  reports  that  in  an  examination 
of  cases  at  the  University  Hospital,  Philadelphia,  14  per  cent, 
gave  a  positive  Wassermann. ^^ 
5 


66        THE  PREVALENCE  OF  SYPHILIS 

Williams  and  Kolmer^^  performed  the  Wassermann 
reaction  on  300  gynecological  cases  such  as  might  be  met 
with  in  the  average  gynecological  dispensary  and  ward 
service  in  Philadelphia,  no  selection  being  made  as  to  the 
type  of  lesion  present.  Three  antigens  were  used,  including 
a  cholesterinized  alcoholic  extract  of  human  heart.  Of  208 
white  cases,  35,  or  20.2  per  cent.,  gave  positive  reactions, 
while  of  92  negroes,  33,  or  35.8  per  cent.,  gave  positive 
reactions.  This,  however,  included  partial  reactions.  Of 
the  total  series  of  300,  36,  or  12  per  cent.,  gave  strongly 
positive  reactions.  The  percentage  of  syphilis  among  these 
cases  may  therefore  be  placed  at  not  less  than  12  per  cent, 
and  as  probably  22  per  cent. 

Washington. — ^Ladd^^  reported  statistics  compiled  on  the 
basis  of  1000  Wassermann  reactions  performed  at  the 
Casualty,  Washington  Asylum  and  George  Washington 
Hospitals.  Of  425  dispensary  patients  at  the  Casualty  and 
Washington  Asylum,  25.5  per  cent,  gave  double-plus  reac- 
tions, 21.7  per  cent,  were  partial  reactions  and  52.8  per  cent, 
were  negative.  Of  these  patients,  68.8  per  cent,  were  white 
and  31.2  per  cent,  were  colored,  and  of  the  double-plus 
reactions,  10.9  per  cent,  were  in  the  white  race  and  14.6 
per  cent,  in  the  colored  race.  Of  449  white  patients  in  the 
wards  of  the  George  Washington  Hospital,  10.4  per  cent, 
were  double  plus,  18.4  gave  partial  reactions  and  71.2  per 
cent,  were  negative.  Of  these  patients  43  per  cent,  were 
females  furnishing  3.6  per  cent,  of  the  positive  results,  while 
57  per  cent,  were  males,  furnishing  6.8  per  cent,  of  the  positive 
reactions.  Of  126  private  cases,  14.1  per  cent,  were  double 
plus,  23.4  per  cent,  had  partial  reactions  and  62.5  per  cent, 
were  negative.  There  were  more  partial  reactions  among 
the  white  than  the  colored  population,  and  Ladd  thought 
this  was  due  to  the  fact  that  the  white  race  has  pursued 
treatment  more  faithfully.  He  concluded  from  these  figures 
that  the  percentage  of  positive  reactions  in  the  general 
population  might  be  estimated  at  17  per  cent.  We  have 
already  pointed  out  the  danger  of  applying  one  set  of  statistics 
to  the  entire  population. 

I  have  also  made  an  endeavor  to  study  the  prevalence  of 


STATISTICS  FROM  DIFFERENT  GROUPS 


67 


syphilis  by  applying  the  Wassermann  reaction  to  several 
institutions  in  Washington,  and  also  to  private  patients. 
A  special  effort  was  made  to  obtain  female  patients  because 
there  is  very  little  evidence  obtainable  covering  the  prev- 
alence of  syphilis  among  women.  The  Women's  Clinic 
and  the  Columbia  Hospital  for  Women  very  kindly  sent 
me  specimens.  While  I  have  not  obtained  all  admissions 
from  these  institutions  the  specimens  have  been  random, 
and  at  various  periods  certain  physicians  have  sent  all 
admissions  to  their  wards.  All  varieties  of  diseases  are 
included,  but  especially  gynecological  conditions.  The 
private  patients  were  obtained  from  several  physicians  in 
Washington  who  have  made  a  practice  of  sending  me  all 
their  new  cases  for  a  Wassermann  reaction.  The  results  of 
this  work  are  shown  in  the  following  table: 

WHITE  WOMEN. 


Place. 

Total. 

Positive. 

Plus. 

Plus  minus. 

Negative. 

No. 

Per 

cent. 

No. 

Per 

cent. 

No. 

Per 

cent. 

No. 

Per 
cent. 

Women's  Clinic 
Columbia    Hospital 
Private  cases 

150 

188 
417 

13 
21 
17 

8.66 

11.17 

4.07 

16 
27 
24 

10.66 

14.36 

5.75 

14 
16 
36 

9.33 

8.51 
8.63 

107 
124 
340 

71.33 
65.95 
81.53 

Total     .      .      . 

755 

51 

6.75 

67 

8.87 

66 

8.74 

571 

75.62 

WHITE  MEN. 


Soldiers'  Home*     -. 
Private  cases 

621 
430 

97 
23 

15.6 
5.34 

85 
15 

13.6 
3.49 

93 
29 

14.9 
6.74 

346 
363 

55.7 
84.41 

Total     .      .      . 

1051 

120 

11.41 

100 

9.51 

122 

11.60 

709 

67.46 

As  the  hospital  cases  all  come  from  the  poorer  classes, 
while  the  private  cases  come  from  the  better  classes,  these 
figures  are  believed  to  represent  a  fair  average  of  the  per- 
centage to  be  expected  among  the  sick  of  these  classes  in 
Washington,  so  far  as  the  facts  may  be  determined  by  the 

*  Published  in  Bulletin  No.  8,  W.  D.,  Office  of  the  Surgeon-General. 


68        THE  PREVALENCE  OF  SYPHILIS 

use  of  the  Wassermann  reaction.  It  is  to  be  expected  that 
these  figures  would  be  considerably  higher  if  the  serological 
evidence  could  have  been  combined  with  the  clinical  findings. 
Unfortunately  this  was  impossible. 

Tuberculous  Patients. — Syphilis  has  long  been  suspected 
as  a  predisposing  cause  of  tuberculosis,  a  fact  that  has  been 
exemplified  in  the  expression  "Syphilis  makes  the  bed  for 
tuberculosis."  Brock/^  as  a  result  of  an  investigation  of 
7660  consecutive  South  African  natives,  among  whom  tuber- 
culosis in  any  form  was  practically  unknown  at  that  time, 
comes  to  the  following  interesting  conclusions : 

1.  Thirty-five  per  cent,  of  natives  have  a  fibroid  condi- 
tion of  the  lungs. 

2.  Sixty-eight  per  cent,  have  indurated  enlargement  of  the 
epitrochlear  gland. 

3.  Both  conditions  result  from  syphilis,  and  nearly  80  per 
cent,  of  the  natives  have  one  or  both  conditions  present. 

4.  Syphilis  prepares  the  way  for  tuberculosis  and  is  in  all 
probability  the  chief  cause  for  the  great  prevalence  of,  and 
the  high  mortality  from,  the  latter  disease  in  the  natives 
engaged  in  mine  work  on  the  Rand. 

5.  Syphilis  plays  a  role  in  the  production  of  lung  diseases 
in  the  youth  and  adult,  the  great  importance  of  which  has 
not  been  recognized. 

In  accordance  with  such  considerations  it  would  be 
expected  that  syphilis  would  be  found  to  be  more  prevalent 
among  the  tuberculous  than  among  those  ill  from  other 
causes.  That  such  is  the  fact  is  indicated  by  some  of  the 
following  investigations : 

Letulle,  Bergeron  and  Lepine^*  investigated  the  prevalence 
of  syphilis  among  this  class  of  patients  in  Paris,  and  for  more 
than  a  year  performed  the  Wassermann  reaction  on  all 
patients  male  or  female  admitted  for  tuberculosis.  Thus 
of  346  tuberculous  patients  64  gave  positive  reactions  and  8 
were  doubtful.  At  least  19  per  cent,  are  therefore  shown  to 
be  infected  with  syphilis  on  the  basis  of  the  Wassermann 
reaction  alone.  The  authors  state  that  "In  Paris  among 
the  patients  in  hospital  for  pulmonary  tuberculosis,  one- 
fifth  at  least  suffer  from  syphilis  more  or  less  latent  but  which 


STATISTICS  FROM  DIFFERENT  GROUPS  G9 

is  still  in  full  activity.  This  is  shown  by  the  Wassermann 
and  confirmed  at  all  points  by  our  pathological  investiga- 
tions." Vedder^^  investigated  the  prevalence  of  syphilis 
among  soldiers  discharged  from  the  army  for  tuberculosis. 
All  patients  at  Fort  Bayard  at  the  time  were  included  except 
those  having  a  history  of  syphilis,  and  a  Wassermann 
reaction  was  performed  on  all  of  them.  Of  the  211  patients 
so  examined,  36,  or  17  per  cent.,  gave  a  double-plus  reaction, 
while  17  per  cent,  more  gave  a  plus  reaction.  There  were 
17  patients  known  to  be  syphilitic,  and  if  those  known  to  be 
infected  are  added  to  those  giving  a  double-plus  Wassermann 
reaction,  of  a  total  of  229  patients,  53,  or  23.2  per  cent.,  were 
syphilitic.  Snow  and  Cooper^*^  repeated  this  work  at  Fort 
Bayard,  also  using  the  Wassermann  reaction  on  all  cases, 
but  with  a  somewhat  different  technic  than  that  used  by 
Vedder.  Of  290  patients  examined,  these  authors  found  44, 
or  14.8  per  cent.,  to  be  surely  syphilitic,  and  58,  or  20  per 
cent.,  who  were  surely  or  probably  syphilitic.  Lyons" 
reports  29,  or  6.2  per  cent.,  positive  out  of  471  tuberculous 
patients,  while  12,  or  3  per  cent,  more,  gave  partial  reactions. 
Jones^^  reported  73,  or  29  per  cent.,  positive  out  of  251 
patients  coming  to  the  public  clinics,  but  many  of  these 
were  partial  reactions.  Out  of  189  patients  from  a  sanatorium 
who  were  undoubtedly  tuberculous  there  were  11  per  cent, 
of  three-plus  reactions,  17  per  cent,  of  two-plus  reactions  and 
25  per  cent,  of  plus  reactions.  The  original  Wassermann 
technic  was  used  with  a  three-plus  reading.  Of  the  patients 
70  per  cent,  were  males  and  30  per  cent,  females,  and  the 
percentage  of  positive  reactions  was  about  the  same  for  both 
sexes.  Petroff,^^  using  a  cholesterinized  heart  extract  for 
antigen,  found  that  of  376  cases,  82,  or  21.8  per  cent.,  gave 
a  positive  Wassermann  reaction.  Ford^"**  examined  328 
patients  at  the  Loomis  Sanitarium,  of  whom  302,  or  92  per 
cent.,  were  negative,  and  only  2  per  cent,  showed  a  per- 
sistently positive  reaction,  and  the  remainder  gave  partial 
reactions.  A  cholesterinized  antigen  was  used,  but  nothing 
is  said  as  to  the  social  status  of  the  patients,  which  it  is 
•thought  may  explain  the  remarkably  low  percentage  found 
in  this  series.     The  statement  is  madei°i  ^j^^t  Wassermann 


70 


THE  PREVALENCE  OF  SYPHILIS 


tests  were  made  on  175  tuberculous  patients  at  the  Corlears 
Tuberculosis  Clinic.  Of  these,  154,  or  88  per  cent.,  were 
negative,  14,  or  8  per  cent.,  were  positive  and  9,  or  5.1  per 
cent.,  gave  partial  reactions.  Subsequent  findings  con- 
firmed the  diagnosis  of  syphilis  in  all  cases  that  gave  a  strongly 
positive  reaction,  and  in  some  that  were  reported  weakly 
positive.  Through  the  kindness  of  Dr.  H.  J,  Corper  I  am 
able  to  quote  the  results  which  he  has  obtained  from  routine 
examinations  of  patients  at  the  Chicago  Tuberculosis 
Sanitarium  for  the  last  three  years  (1915-1917).  The 
Wassermann  reaction  was  performed  on  all  admissions,  using 
the  Noguchi  hemolytic  system  and  a  non-cholesterinized 
beef-heart  antigen.  Only  those  cases  giving  complete  fixa- 
tion of  complement  were  considered  positive.  The  results 
may  be  tabulated  as  follows : 


Male. 

Female. 

Age  in  years. 

Total. 

Positive. 

Positive, 
per  cent. 

Total. 

Positive. 

Positive, 
per  cent. 

0  to    5 
6  to  15 
16  to  25 
26  to  40 
41  to  60 
Over  61 
Unknown 

43 
207 
341 
551 
212 
14 
27 

1 

16 
14 
50 
19 
1 
0 

2.3 
7.7 
4.1 
9.0 
8.9 
7.1 
0.0 

31 
265 
443 
531 
111 
5 

13 

1 
14 
17 
37 
11 
0 
0 

3.2 
5.2 
3.8 
6.9 
9.9 
0.0 
0.0 

Total 

1395 

101 

7.2 

1399 

80 

5.7 

From  the  above  table  it  will  be  seen  that  of  a  total  of  2794 
cases  of  both  sexes  and  all  ages  a  positive  Wassermann  was 
obtained  in  181,  or  6.5  per  cent.  This  is  believed  to  be  an 
absolute  minimum,  for  it  must  be  remembered  that  partial 
reactions  are  not  given,  that  a  cholesterinized  antigen  was 
not  used,  and  that  many  cases  known  to  be  syphilitic  were 
probably  excluded  and  treated  elsewhere.  Many  are  thus 
treated  at  the  County  Hospital.  Among  males  of  twenty- 
six  to  forty  years  of  age  the  percentage  is  at  least  9,  and  may 
be  estimated  at  a  considerably  higher  figure. 

Criminals. — Criminals  can  hardly  be  included  with  the 
sick,  nor  can  they  be  classed  with  the  normal  population. 


STATISTICS  FROM  DIFFERENT  GROUPS  71 

According  to  Boudreau^''^  the  Wassermann  reaction  has  been 
performed  on  all  admissions  to  the  prison  at  Auburn,  N.  Y., 
except  those  sent  from  Sing  Sing.  This  rule  has  been  in 
force  since  December,  1915.  During  the  following  five 
months  there  were  279  admissions,  of  which  47,  or  16.8  per 
cent.,  had  positive  reactions.  In  addition  the  test  was 
made  on  all  inmates  of  the  women's  prison,  and  out  of  127 
specimens,  43,  or  33.8  per  cent.,  were  positive. 

Kramer^o^  examined  1583  out  of  the  1800  inmates  in  the 
Ohio  penitentiary  on  July  1,  1915:  288,  or  18.1  per  cent., 
gave  either  positive  or  partial  reactions  as  follows:  18  were 
four  plus,  35  were  tliree  plus,  149  were  two  plus  and  86  were 
plus.  Of  these  288,  43,  or  14.9  per  cent.,  gave  a  clinical 
history  of  some  sort.  Of  the  colored  population,  58,  or  13.4 
per  cent.,  were  positive;  while  108,  or  20.9  per  cent.,  of  the 
American-born  population  were  positive.  This  low  finding 
among  the  colored  prisoners  is  remarkable  and  unexplained. 
Vedder^^  investigated  the  prevalence  of  syphilis  among 
the  military  prisoners  confined  at  Fort  Leavenworth  and  Fort 
Jay.  While  these  men  are  not  criminals  they  include  a  cer- 
tain number  of  defective  and  abnormal  individuals.  Of  1 145 
prisoners  examined,  82  were  under  treatment  for  syphilis, 
101  more  had  a  double-plus  Wassermann;  so  that  183,  or 
15.98  per  cent.,  may  be  regarded  as  undoubtedly  syphilitic. 
In  addition  to  this  there  were  65,  or  5.67  per  cent.,  who  had 
a  plus  Wassermann. 

Thomas^"^  reported  that  for  a  year  a  Wassermann  reaction 
was  made  on  every  prisoner  admitted  to  the  Naval  Prison 
at  Portsmouth.  Of  the  280  tested,  59  gave  a  history  of  a 
chancre,  and  of  these  49  had  a  positive  Wassermann.  None 
of  the  221  cases  denying  a  history  of  infection  had  a  positive 
Wassermann,  While  these  figm-es  are  almost  too  good  to  be 
true,  and  it  can  hardly  be  believed  that  not  a  single  case  out 
of  221  denying  infection  should  have  a  positive  Wassermann 
if  accepted  at  their  face  value;  this  indicates  that  21  per 
cent,  of  the  prisoners  at  Portsmouth  are  syphilitic. 

The  statistics  of  the  New  York  Health  Department  quoted 
by  Pollitzer^°5  are  of  great  interest.  He  states  that  35  per 
cent,  of  the  3809  cases  from  the  criminal,  degenerate  and 


Number 

Positive, 

of  tests. 

Positive. 

per  cent. 

391 

45 

11.5 

544 

37 

6.8 

253 

62 

24.5 

2621 

1209 

45.7 

72  THE  PREVALENCE  OF  SYPHILIS 

derelict  class  have  syphilis,  the  distribution  being  shown  by 
the  following  table : 

SYPHILIS   IN  THE  DEEELICT   CLASS. 


Tombs  prison  men  awaiting  trial 
Hart's  Island  Reformatory — boys 
Penitentiary,  Blaekwell's — both  sexes  .      253 
Workhouse — both  sexes 2621 

Sick  Children. — The  prevalence  of  syphilis  among  children 
depends  almost  entirely  upon  the  prevalence  of  inherited  or 
congenital  syphiHs.  Such  children  naturally  tend  to  be 
found  in  hospitals  and  institutions.  While  the  percentage 
found  in  general  hospitals  for  children  is  not  large  the  per- 
centage of  syphilitic  children  in  institutions  for  the  feeble- 
minded may  be  quite  high.  Much  work  has  been  done  along 
this  line,  and  it  cannot  all  be  quoted. 

ChurchilP''^  tested  a  series  of  101  hospital  children  by  the 
Wassermann  reaction.  None  of  these  children  were  admitted 
for  syphilis,  yet  38  per  cent,  of  the  cases  gave  a  positive 
reaction.  Some  of  these  were  undoubtedly  partial  reactions, 
yet  in  investigating  the  clinical  condition  and  history, 
Churchill  came  to  the  conclusion  that  there  were  29  cases, 
or  28  per  cent,  of  syphilitic  children  in  this  series. 

Blackfan,  Nicholson  and  White^"^^  also  examined  101 
infants,  68  of  whom  were  from  a  foundling  hospital  and  33 
from  the  wards  and  out-patient  department  of  the  St.  Louis 
Children's  Hospital.  In  the  first  68.  children  the  Wassermann 
was  negative  in  66,  doubtful  in  1  and  positive  in  1.  In  the 
second  group  the  Wassermann  was  negative  in  32  and  posi- 
tive in  1.  Holt^''^  reported  178  tests  made  on  hospitalized 
children  showing  no  definite  signs  of  syphilis.  Positive 
reactions  were  obtained  in  11  cases,  and  of  these  5  were 
proved  to  be  syphilitic  by  the  subsequent  findings  and  2  were 
probably  syphilitic.  If  the  whole  11  are  counted  as  syphilitic 
this  gives  a  percentage  of  6.1. 

Churchill  and  Austin^"^  made  an  analysis  of  the  literature 
and  an  intensive  study  of  695  patients  in  the  Children's 
Memorial  Hospital,  Chicago.    They  conclude  that,  according 


STATISTICS  FROM  DIFFERENT  GROUPS  73 

to  the  literature,  the  incidence  of  hereditary  syphilis  must 
vary  considerably,  it  being  variously  estimated  at  from  2 
to  14  per  cent,  in  both  Europe  and  America.  Intensive 
study  of  their  own  series  of  695  patients  during  the  winter 
of  1915-1916,  including  both  clinical  and  laboratory  methods, 
indicated  an  incidence  of  3.3  per  cent,  of  hereditary  syphilis. 
The  amount  among  hospital  infants  and  children  in  four 
large  cities  of  the  United  States,  New  York,  St.  Louis, 
Chicago  and  San  Francisco,  appears  to  range  from  2  to  6 
per  cent.  Whitney's  figures^^  indicated  that  of  890  children 
in  the  out-patient  department  of  the  University  of  California, 
26,  or  2.9  per  cent.,  were  syphilitic.  Walker^^  examined  480 
inmates  of  an  institution  for  the  feeble-minded  in  Baltimore, 
boys  and  girls,  representing  State  charges,  and  found  that 
less  than  3  per  cent,  had  a  positive  Wassermann. 

As  showing  the  higher  incidence  of  syphilis  in  certain 
institutions,  we  may  quote  several  investigators. 

Johnson""  performed  a  Wassermann  reaction  on  224 
children  from  the  open-air  schools  of  St.  Louis.  These 
schools  are  maintained  for  children  suffering  from  anemia 
and  malnutrition  of  apparently  unknown  origin.  Of  these 
children,  37,  or  16.5  per  cent.,  gave  a  four-plus  reaction,  39, 
or  17.4  per  cent.,  gave  a  three-plus  reaction,  22,  or  9.8  per 
cent.,  gave  a  two-plus  reaction,  28,  or  12.5  per  cent.,  gave  a 
plus  reaction  and  only  98,  or  48.8  per  cent.,  gave  a  clean 
negative.  If  the  four-  and  three-plus  reactions  are  counted 
as  indicating  syphilis,  76,  or  33.9  per  cent.,  of  these  children 
were  luetic. 

Lucas^i  found  that  out  of  111  children  from  two  to  nineteen 
years  of  age  the  Wassermann  reaction  was  positive  in  35, 
or  31.5  per  cent.  These  were  all  abnormal  children,  mentally 
backward,  epileptic  and  suffering  from  various  nervous 
conditions. 

Anderson"^  performed  the  Wassermann  reaction  on  a 
series  of  225  cases  intensively  studied  by  exact  mental 
tests:  41  were  adults  and  184  were  children  and  adolescents; 
41  per  cent,  of  the  adults  and  42.5  per  cent,  of  the  children 
were  mental  defectives.  Of  the  41  adults,  24.6  per  cent, 
had  a  positive  Wassermann,  and  of  the  184  children  and  ado- 


74  THE  PREVALENCE  OF  SYPHILIS 

lescents,  17  per  cent,  had  a  positive  Wassermann.  Anderson 
states  that  in  every  instance  the  Wassermann  reaction 
was  negative  in  those  individuals  classified  as  normal  by 
exact  mental  tests,  so  that  the  percentage  of  positives  for 
the  mentally  deficient  must  have  been  much  higher  than 
indicated  by  the  above  percentages  and  higher  than  the 
figures  obtained  by  other  investigators. 

Haines^^^  found  that  of  68  feeble-minded  children  at  the 
psychopathic  hospital  about  30  per  cent,  were  syphilitic, 
while  the  incidence  of  syphilis  among  all  patients  tested  at 
this  hospital  was  14.7  per  cent.  These  results  agree  closely 
with  those  of  Dean^*^  and  Lippmann^^  who  studied  the  inci- 
dence of  syphilis  among  idiots  in  Germany  by  means  of  the 
Wassermann  reaction  and  the  clinical  findings. 

On  the  other  hand,  quite  different  results  are  recorded  as 
the  result  of  an  investigation  of  weak-minded  in  Denmark,^^* 
in  which  out  of  2061  weak-minded  patients  of  all  ages  only 
31,  or  1.5  per  cent.,  gave  a  positive  reaction.  However, 
such  figures  are  altogether  too  good  to  be  true.  It  will 
probably  be  admitted  that  the  percentage  of  syphilis  in  the 
general  population  in  Denmark  must  be  higher  than  this, 
and  there  is  no  reason  to  suppose  that  the  percentage  among 
weak-minded  is  lower  than  that  among  the  surrounding 
population,  but  rather  the  reverse.  It  would  seem  therefore 
that  this  particular  Wassermann  technic  must  have  been 
inefficient  in  spite  of  the  fact  that  Boas  was  one  of  the 
collaborators. 

Haines^^^  also  studied  the  incidence  of  syphilis  among 
juvenile  delinquents  and  found  undoubted  evidence  of 
syphilitic  infection  among  delinquent  boys  andigirls  in  from 
15  to  20  per  cent,  of  the  cases.    His  figures  are  as  follows: 

Boys. 

Total  tested 147 

Positive  Wassermann       ....        34 
Per  cent,  positive 23 . 1 

In  such  studies  of  congenital  syphilis  by  means  of  the 
Wassermann  reaction,  higher  percentages  are  obtained  the 
younger  the  children  studied,  because  the  Wassermann  reac^ 


Giris. 

Total. 

218 

365 

42 

76 

19.2 

20.8 

STATISTICS  FROM  DIFFERENT  GROUPS  75 

tion  is  always  more  strongly  positive  in  early  syphilis  than  in 
tertiary  and  so-called  latent  syphilis.  This  fact  is  brought 
out  by  Dean's  figures  on  idiots,  which  were  as  follows: 


Number 
examined. 

Positive. 

Positive, 
per  cent. 

.      94 

20 

21.27 

.    142 

24 

16.9 

.      66 

4 

6.06 

Patients  ten  years  and  less  . 
Patients  eleven  to  fifteen  years 
Patients  sixteen  to  twenty  years 

However,  it  should  be  noted  that  under  one  year  of  age 
this  rule  appears  to  be  reversed.  Rabinowitsch^  examined 
infants  at  a  creche  in  Charkow,  Russia.  He  made  a  total 
of  1108  Wassermann  examinations,  of  which  153  were  posi- 
tive. But  732  of  these  made  on  the  first  examination  gave 
only  83,  or  11.33  per  cent,,  positive;  308  who  were  examined 
the  second  time  at  a  later  age  resulted  in  16.2  per  cent,  of 
positives,  while  on  the  third  examination  there  were  29.4 
per  cent,  of  positives. 

Dr.  Sessions,  superintendent  of  the  Indiana  Girls'  School, 
an  institution  for  delinquent  girls,  reported  an  examination 
of  243  girls  in  that  school  in  May,  1915:  55,  or  22.6  per 
cent.,  gave  positive  reactions,  and  Dr.  Sessions  thought 
that  in  45  of  these  girls  the  disease  was  congenital,  and  that 
not  one  of  these  45  had  a  well-balanced,  dependable  mind.^^^ 

McKay^^^  performed  the  Wassermann  reaction  on  1550 
inmates  in  the  institution  for  the  feeble-minded  at  Columbus, 
Ohio.  The  patients  tested  ranged  in  age  from  six  to  sixty- 
one  years  of  age:  134,  or  8.6  per  cent.,  gave  positive  reactions. 
In  only  2  of  these  cases  was  there  a  history  of  syphilitic 
infection,  sc^that  in  132,  or  8.5  per  cent.,  the  infection  was 
presumably  congenital.  The  youngest  patient  having  a 
positive  reaction  was  seven  years  old  and  the  oldest  was 
sixty-one. 

Moulton"8  tested  600  boys  at  the  Minnesota  School  for 
the  Feeble-minded.  Noguchi's  modification  with  the  acetone- 
insoluble  fraction  for  antigen  was  used:  523,  or  87.1  per  cent., 
were  negative,  while  the  remainder  gave  complete  or  partial 
reactions;  16,  or  2.6  per  cent.,  gave  complete  inhibition,  and 
61,  or  10.1  per  cent.,  gave  partial  reactions.    Had  a  stronger 


76 


THE  PREVALENCE  OF  SYPHILIS 


antigen  been  used,  undoubtedly  some  of  these  partial  reac- 
tions would  have  been  completely  positive. 

Dawson^'3  reports  the  results  of  an  examination  of  1113 
inmates  of  the  Sonoma  State  Home  at  Eldridge,  California, 
using  the  Noguchi  technic.  Positive  tests  were  obtained  in 
30  males  and  23  females,  a  total  of  53,  or  about  5  per  cent. 
Ages  were  from  nine  to  sixty-five  years. 

Individuals  Who  are  Presumably  Healthy. — While  it  is  com- 
paratively easy  to  obtain  information  in  regard  to  the  exist- 
ence of  syphilitic  infection  among  those  individuals  who  are 
sick  and  have  presented  themselves  for  treatment,  it  is  a 
matter  of  great  difficulty  to  obtain  any  evidence  in  regard 
to  the  prevalence  of  syphilis  among  individuals  who  are 
healthy  and  therefore  do  not  come  under  observation,  and 
it  is  due  to  this  fact  chiefly  that  our  information  in  regard  to 
the  prevalence  of  syphilis  in  the  community  as  a  whole  is  so 
meager.  It  occurred  to  the  writer  that  such  information 
could  be  readily  obtained  with  regard  to  the  young  adult 
males  of  the  community  by  making  surveys  of  the  men  in 
the  army  and  also  of  the  recruits  accepted  for  the  army. 
This  work  was  accordingly  carried  out  and  the  results  have 
been  published. ^^  So  far  as  healthy  white  males  are  con- 
cerned, these  results  may  be  summarized  as  follows:* 


Survey. 

Total 
exam- 
ined. 

Known 
syphilitics. 

+  + Was- 
sermann. 

Undoubted 
syphilitics. 

+  Wasser- 
mann. 

Estimate 

of  total 

probable 

syphilitics. 

Recruits    . 
Cadets 

White  enlisted 
men 

1019 
621 

1577 

0 
0 

3.44 

7.75 
2.57 

4.77 

7.75 
2.57 

8.21 

9.02 

2.89 

7.87 

16.77 
5.46 

16.08 

The  cadets  were  from  seventeen  to  twenty-seven  years  old 
and  may  be  taken  as  representative  of  the  better  class  of- 
young  men  that  are  found  in  our  colleges.  The  enlisted  men 
ranged  from  eighteen  to  forty  years  of  age,  but  the  majority 


*  Foucar  made  a  Wassermann  survey  of  500  white  soldiers  at  Honolulu ,  of 
whom  8.25  per  cent,  gave  a  double-plus  reaction.  Report  of  Surgeon- 
General,  1916,  p.  193. 


.     STATISTICS  FROM  DIFFERENT  GROUPS  77 

were  between  twenty  to  twenty-five  years  of  age  and  may  be 
taken  as  representing  the  great  middle  class  of  mechanics, 
artisans  and  untrained  laborers.  The  evidence  indicated  that 
the  percentage  of  syphilitic  infections  increased  with  age. 

Of  25  men  of  eighteen  years  of  age,  1,  or  4  per  cent.,  was 
positive. 

Of  64  men  of  nineteen  years  of  age,  2,  or  3.12  per  cent.,  were 
positive. 

Of  86  men  of  twenty  years  of  age,  7,  or  8.14  per  cent.,  were 
positive. 

The  average  percentage  for  five-year  periods  was  as  follows: 

18  to  22 10.35 

23  to  27 16.58 

28  to  32 20.85 

33  to  37 24.22 

37  to  41 28.82 

The  recruits  constituted  an  especially  interesting  class 
because  they  were  not  yet  a  part  of  the  army  and  therefore 
represented  conditions  as  found  in  civil  life,  except  for  the 
fact  that  as  these  men  had  already  passed  two  physical  exami- 
nations, and  evident  syphilitics  had  been  rejected,  it  may  be 
assumed  that  there  was  a  higher  percentage  of  syphilitic 
infections  among  the  men  of  this  class  in  civil  life  than  among 
the  picked  recruits. 

From  this  study  the  writer  drew  the  conclusions : 

1.  We  may  estimate  that  about  20  per  cent,  of  the  young 
adult  male  population  of  the  class  from  which  the  army  is 
recruited  are  infected  with  syphilis. 

2.  We  may  estimate  that  about  5  per  cent,  of  the  young 
men  in  our  colleges  are  syphilitic. 

These  results  were  sufficiently  interesting  to  warrant 
further  study,  and  accordingly,  arrangements  were  made 
by  the  Surgeon-General  and  the  Adjutant-General  to  have  a 
Wassermann  reaction  performed  on  each  recruit  accepted 
for  the  army.  Each  recruit  depot  was  equipped  to  perform 
this  reaction,  and  a  medical  officer  was  detailed  at  each  depot 
to  perform  this  work.  The  same  technic  was  used  by  all 
of  these  officers,  and  was  that  used  in  the  previous  work.*^^ 

*  See  Appendix,  p.  265. 


78 


THE  PREVALENCE  OF  SYPHILIS 


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STATISTICS  FROM   DIFFERENT  GROUPS 


79 


The  work  was  commenced  about  October,  1915,  and  the 
results  for  the  first  year  are  tabulated  on  the  opposite  page. 

At  this  time  the  above-named  officers  were  relieved  from 
this  duty.  The  work  was  continued  but  was  performed  by  a 
personnel  unknown  to  the  writer,  and  part  of  the  time  at 
least  by  enlisted  men  of  the  Hospital  Corps  who  had  received 
a  certain  amount  of  training  under  the  previous  medical 
officers  performing  the  work.  The  results  of  the  work  carried 
on  under  these  conditions  during  1916-1917  may  be  tabulated 
as  follows: 


Double  plus. 

Plus. 

Plus-minus. 

Negative. 

Place. 

No. 

Per 

cent. 

No. 

Per 
cent. 

No. 

Per 
cent. 

No. 

Per 
cent. 

Total. 

Fort  Logan,  Col. 
Jefferson  Barracks, 

Mo 

Fort  Slociim,  N.  Y.  . 
Columbus  Barracks, 

Ohio      .... 
Fort  McDowell.  Cal. 

143 

461 
101 

84 
99 

5.68 

5.66 
1.40 

2.95 
4.10 

55 

322 
234 

158 

27 

2.18 

3.95 
3.26 

5.56 
1.12 

37 

351 
1298 

380 
41 

1.46 

4.31 
18.10 

13.37 
1.70 

2,281 

7,001 
5,536 

2,219 
2,244 

90.66 

86.06 
77.22 

78.10 
93.07 

2,516 

8.135 
7,169 

2,841 
2,411 

Total 

888 

3.84 

796 

3.45 

2107 

9.13 

19,281 

83.56 

23  072 

It  is  very  difficult  to  pass  judgment  on  these  figures.  The 
percentage  of  positive  reactions  obtained  during  the  second 
year  (3,84  +  +  and  3.45  +)  are  much  lower  than  those 
obtained  during  the  first  year  (5.64  H — (-  and  7.04  +). 

Since  the  qualifications  of  the  workers  who  performed  the 
test  during  the  second  year  are  unknown  it  is  only  natural 
to  believe  that  the  results  obtained  during  the  first  year  are 
the  more  accurate  and  give  a  better  idea  as  to  the  prevalence 
of  syphilis  among  accepted  recruits  for  the  army. 

But  there  is  some  variation  in  the  figures  obtained  by 
different  workers  even  during  the  first  year,  and  it  is  a  remark- 
able coincidence  that  the  figures  obtained  by  Craig  and 
Nichols  were  constantly  higher  than  the  figures  obtained  by 
other  workers.    The  results  obtained  by  these  two  workers 


89  THE  PREVALENCE  OF  SYPHILIS 

are  almost  identical  and  only  slightly  below  those  obtained 
by  the  ■WTiter,  as  may  be  seen  from  the  following  tabulation : 


Total 

Double 

Per  cent. 

number. 

plus. 

Plus. 

positive. 

Vedder 

.      .      1019 

7.75 

9.02 

16.77 

Craig  . 

.      .      1139 

9.06 

4.48 

13.54 

Nichols     . 

.      . .   2310 

9.22 

4.07 

13.29 

The  difference  between  the  results  obtained  by  Craig  and 
Nichols  and  the  other  three  workers  during  the  first  year 
consists  in  the  higher  percentage  of  double-plus  reactions 
obtained  by  Craig  and  Nichols  and  the  higher  percentage 
of  plus  reactions  obtained  by  the  other  three  workers.  If 
all  double-plus  and  plus  reactions  be  added  together  there 
is  substantial  uniformity  of  result.  Thus  12.68  per  cent,  of 
positive  reactions  were  obtained  in  a  total  of  11,933  cases. 
On  this  basis  we  may  estimate  that  about  13  per  cent,  of 
accepted  recruits  for  that  year  were  syphilitic. 

Since  these  figures  agree  so  closely  with  my  own  the  possi- 
bility that  the  low  figures  for  the  second  year  when  only 
7.29  per  cent,  of  positive  reactions  were  obtained  were  due 
to  imperfections  in  technic  must  be  considered.  It  is  also 
possible  that  at  least  a  part  of  the  decrease  in  positive 
reactions  during  the  second  year  of  the  work  was  due  to  the 
fact  that,  owing  to  the  possibility  of  active  service,  a  younger 
and  better  class  of  recruits  were  secured  during  the  last  year. 
It  has  been  the  policy  of  the  War  Department  to  discourage 
reenlistments  except  in  the  case  of  non-commissioned  officers, 
and  especially  valuable  men,  and  during  this  year  the  per- 
centage of  reenlistments  was  very  low.  This  would  cut. 
down  the  percentage  of  men  over  thirty  years  of  age  very 
materially.  In  former  years  approximately  16  per  cent,  of 
the  total  number  of  recruits  were  over  thirty  years  of  age, 
and  in  all  the  groups  studied  by  Vedder  the  percentage  of 
positive  reactions  increased  steadily  with  increasing  age. 
The  fact  that  the  percentage  of  syphilis  among  accepted 
recruits  is  materially  lower  as  the  age  decreases  is  also  shown 
by  a  survey  made  by  Hunger, ^^^  who  made  a  Wassermann 
survey  of  500  accepted  recruits  for  the  nav}^  Of  these  men, 
5,  or  1  per  cent.,  were  double  plus,  and  3,  or  0.6  per  cent., 


STATISTICS  FROM  DIFFERENT  GROUPS 


81 


were  plus.  It  is  not  to  be  supposed  that  there  is  any  essential 
difference  between  the  class  of  men  secured  for  the  navy  and 
that  secured  for  the  army;  but  there  is  an  important  differ- 
ence in  the  age,  as  the  average  age  of  these  500  naval  recruits 
was  only  nineteen.  The  age  seventeen  furnished  the  largest 
number  of  any  one  year  and  73  per  cent,  were  under  twenty- 
one.  All  of  the  men  giving  double-plus  reactions  were  over 
twenty-one.  The  recruits  surveyed  by  Vedder  were  from 
eighteen  to  forty  years  of  age,  but  61  per  cent,  were  between 
twenty-one  and  twenty-four  years  of  age,  and  16  per  cent, 
were  over  thirty  years  of  age. 

As  these  are  all  men  who  have  been  selected  by  passing 
one  rather  severe  physical  examination  in  the  coiu-se  of  which 
all  cases  of  obvious  syphilis  were  rejected,  it  should  be  safe 
to  estimate  that  in  the  civil  community,  men  of  the  corre- 
sponding groups  may  run  from  1  to  5  per  cent,  higher;  so 
that  the  original  estimate  by  Vedder  of  20  per  cent,  for  the 
young  adult  male  population  of  the  class  from  which  the 
army  is  recruited  is  approximately  correct  for  men  from 
twenty-five  to  thirty  years  of  age,  but  is  probably  too  high 
for  men  from  seventeen  to  twenty-five  years  of  age. 

Through  the  kindness  of  Dr.  Huron  W.  Lawson,  of  Wash- 
ington, D.  C,  the  writer  has  been  able  to  perform  a  Wasser- 
mann  survey  on  856  consecutive  candidates  for  the  police 
force,  the  results  of  which  are  as  follows: 


Total 
examined. 

Double  plus. 

Plus. 

Plus-minus. 

Negative. 

No. 

Per 
cent. 

No. 

Per 

cent. 

No. 

Per 
cent. 

No. 

Per 
cent. 

856       ...       . 

54     1  6.30 

77 

8.99 

91 

10.63 

634 

74.06 

'  From  this  we  see  that  15.29  per  cent,  of  these  candidates 
gave  either  a  double-plus  or  a  plus  reaction,  so  that  we  may 
estimate  that  at  least  from  15  to  16  per  cent,  of  these  men 
are  syphilitic.  These  men  are  almost  all  robust,  apparently 
healthy  men,  but  they  are,  as  a  class,  more  intelligent  than 
6 


82  THE  PREVALENCE  OF  SYPHILIS 

the  average  recruit  for  the  army.  Since  only  a  few  men 
present  themselves  at  a  time  for  this  examination,  in  order 
to  obtain  this  number  of  men  the  work  was  continued  over 
about  three  years.  It  is  believed  therefore  that  this  repre- 
sents a  fair  average  of  the  material  presenting  for  the  police 
force  of  the  city  of  Washington,  and  these  figures  obtained 
in  strong  and  apparently  healthy  males  in  civil  life  are  an 
additional  confirmation  of  the  correctness  of  the  writer's 
original  estimate  of  the  prevalence  of  syphilis  among  the 
young  adult  males  of  the  community,  and  indicate  that  there 
is  no  reason  to  suppose  that  the  incidence  of  the  disease  is 
any  higher  among  those  men  who  present  themselves  as 
candidates  for  the  army  than  among  other  young  males  of 
the  general  community  belonging  to  the  same  social  scale. 

Candidates  for  a  Commission  in  the  Army.^The  writer  has 
also  had  an  opportunity  to  make  a  Wassermann  survey  of  a 
large  number  of  young  men  who  have  been  candidates  for  a 
commission  in  several  training  camps  in  the  Eastern  Depart- 
ment. Many  of  these  were  college  men,  a  fair  proportion 
were  non-commissioned  officers  of  the  regular  army,  and 
young  men  in  business  and  various  professions  were  all 
included.  Taken  as  a  whole,  they  may  fairly  be  considered 
as  representative  of  a  more  highly  educated  class  than  the 
class  applying  for  enlistment.  Some  of  them  have  come  from 
the  best  of  homes,  and  probably  no  better  group  of  men 
could  have  been  selected  to  represent  the  great  middle  class. 
While  there  were  a  few  men  over  forty,  the  great  majority  of 
this  group  were  young  men  under  thirty.  In  all,  3203  candi- 
dates for  commissions  were  examined,  with  the  following 
results:  79,  or  2.46  per  cent.,  gave  a  double-plus  reaction; 
109,  or  3.4  per  cent.,  gave  a  plus  reaction;  116,  or  3.61  per 
cent.,  gave  a  plus-minus  reaction;  2899,  or  90.5  per  cent., 
gave  a  negative  reaction.  A  history  of  physical  signs  of 
syphilis  was  obtained  in  many  of  the  positive  cases  and  in  a 
few  of  the  partial  reactions,  so  that  the  incidence  of  syphilis 
in  this  group  may  be  regarded  as  falling  between  2  and 
5  per  cent. 

These  figures  are  much  lower  than  the  percentages  obtained 


STATISTICS  FROM  DIFFERENT  GROUPS  83 

from  surveys  of  enlisted  men  or  candidates  for  enlistment, 
and  are  about  the  same  as  those  obtained  in  the  survey  of 
cadets  at  West  Point.  In  the  latter  case,  however,  as  there 
were  no  clinical  evidences  of  syphilis  among  any  of  the 
cadets,  it  is  probable  that  the  incidence  of  syphilis  among 
these  cadets  is  nearer  2  than  5  per  cent.,  while  among  the 
present  group  of  candidates  for  a  commission  it  is  probable 
that  the  percentage  is  nearer  5  than  2. 

Healthy  Women. — While  information  as  to  the  prevalence 
of  syphilis  may  be  obtained  in  regard  to  women  who  have 
entered  the  hospital  for  some  illness,  it  is  very  difficult,  for 
obvious  reasons,  to  obtain  information  in  regard  to  the  prev- 
alence of  this  disease  among  presumably  healthy  women. 
Such  information  can,  however,  be  obtained  from  maternity 
hospitals,  for  there  is  no  reason  why  women  who  are  admitted 
only  for  pregnancy  should  not  be  considered  as  normal. 
Williams^^^  found  that  of  10,000  consecutive  admissions  to 
the  obstetrical  department  of  the  Johns  Hopkins  Hospital, 
of  which  4600  were  colored,  a  total  of  350  syphilitic  children 
were  born,  a  percentage  of  3.5.  This  does  not  indicate  the 
total  number  of  syphilitic  women,  but  only  those  who  gave 
birth  to  obviously  syphilitic  children.  Of  705  fetal  deaths 
occurring  in  this  series,  273  were  in  the  white  race  and  35 
of  these,  or  12.3  per  cent.,  were  due  to  syphilis;  432  deaths 
occurred  in  the  colored  race,  of  which  151,  or  34.9  per  cent., 
were  due  to  syphilis.  Williams  concludes  that  syphilis  is 
the  greatest  single  cause  of  fetal  death. 

Commisky^^^  in  a  series  of  1822  routine  Wassermann  tests 
on  pregnant  women  found  145,  or  8  per  cent.,  positive;  26, 
or  1.4  per  cent.,  doubtful;  while  11  negatives,  or  0.6  per  cent., 
had  infants  whose  reactions  were  positive  or  doubtful.  Of 
those  positive,  82  per  cent,  gave  no  history  or  clinical  signs 
of  the  disease. 

Falls  and  Moore^^^  examined  160  pregnant  women  from 
fifteen  to  forty-three  years  of  age,  over  90  per  cent,  being 
from  eighteen  to  twenty-two  years  of  age.  Of  118  married 
women  10.6  per  cent,  were  positive,  while  among  44  single 
women  13.6  per  cent,  were  positive.    Of  146  white  women. 


84  THE  PREVALENCE  OF  SYPHILIS 

9.5  per  cent,  were  positive;  while  of  14  colored  women,  28.5 
per  cent,  were  positive.  In  the  discussion  following  this  paper 
Dr.  Losee*  stated  that  routine  Wassermann  tests  had  been 
made  during  the  past  two  years  at  the  New  York  Lying-in 
Hospital  on  2000  antepartum  women,  of  whom  3.05  per 
cent,  were  positive,  and  that  Fildes  in  the  East  End  of  London 
had  observed  3.9  per  cent,  in  677  women. 

Dr.  Reuben  Ottenberg  has  been  so  kind  as  to  send  me  the 
results  of  the  routine  Wassermann  reactions  performed  by 
him  on  cases  of  pregnancy  admitted  to  the  Sloane  Hospital 
for  Women,  New  York,  from  July,  1916,  to  December,  1917. 
A  non-cholesterinized  antigen  was  used.  The  results  are  as 
follows : 

Negative  reactions   .      .      .     2183         87.7  per  cent,  of  the  whole 

Plus-minus  or  plus    ...  38  \         „    ,  <.      e  i.\        i i 

-r^     ,  ,       ,          ^  .„  )        2.4  per  cent,  ot  the  whole 

Double  plus 40  J  '^ 

Positive   3+  or  4+        .      .        227  9.9  per  cent,  of  the  whole 

In  252  cases  tests  were  performed  also  with  a  cholesterinized 
antigen  prepared  after  the  method  of  Walker  and  Swift. 
Of  these. 

Five  listed  as  negative  were  four  plus  with  the  choles- 
terinized antigen. 

Five  listed  as  negative  were  three  plus  with  the  choles- 
terinized antigen. 

Ten  listed  as  negative  were  two  plus  with  the  choles- 
terinized antigen. 

It  will  thus  be  seen  that  the  cases  reported  by  Dr.  Otten- 
berg are  the  result  of  a  very  conservative  reaction  and  must 
be  considered  as  the  minimum  number  of  positive  cases  at 
the  Sloane  Hospital. 

For  several  years  I  have  made  routine  Wassermann  tests 
for  the  Columbia  Hospital  for  Women,  Washington,  D.  C. 
During  certain  times  I  have  also  made  this  test  as  a  routine 
for  Dr.  Lawson's  obstetrical  clinic.     The  following  tabula- 

*  See  Syphilis  in  Mother  and  Infant,  Bulletin  of  the  Lying-in  Hospital 
of  New  York,  June,  1916. 


STATISTICS  FROM  DIFFERENT  GROUPS 


85 


tion  which  includes  only  women  admitted  for  pregnancy, 
shows  the  results  obtained: 


WHITE    WOMEN. 


Num- 
ber 
exam- 
ined. 

Double  plus. 

Plus. 

Plus-minus. 

Negative. 

No. 

Per 
cent. 

No. 

Per 

cent. 

No. 

Per 

cent. 

No. 

Per 

cent. 

Lawson     . 
Columbia 

20 
181 

3 
14 

15.0 
7.73 

4 
15 

20.0 

8.28 

2 
22 

10.0 
12.15 

11 
130 

55.0 

71.82 

Total     . 

201 

17 

8.01 

19 

9.05 

24 

11.94 

141 

70.01 

COLORED   WOMEN. 

Lawson     . 
Columbia 

165 
497 

31 
94 

18.78 
18.91 

25 
56 

15.15 
11.26 

15 
55 

9.09 
11.06 

94 
292 

56.97 

58.75 

Total     . 

662 

125 

18.88 

81 

12.23 

70 

10.57 

386 

58.3 

Counting  double-plus  and  plus  cases  we  may  estimate 
that  17  per  cent,  of  these  white  women  are  syphilitic,  and  it 
is  not  believed  that  this  estimate  is  much  too  high,  for  it  is 
undoubtedly  true  that  these  patients  are  for  the  most  part 
from  the  poor  and  ignorant  classes  and  include  a  fair  sprink- 
ling of  single  women.  Probably  among  the  better  classes 
the  percentage  would  be  nearer  the  3  per  cent,  found  in  the 
New  York  Lying-in  Hospital.  These  figures  may  be  com- 
pared to  the  31.1  per  cent,  of  positive  reactions  found  among 
pregnant  negro  women. 

The  Prevalence  of  Syphilis  among  Negroes. — All  who  have 
had  any  extensive  experience  with  the  negro  race  have 
felt  assured  that  the  incidence  of  venereal  diseases  is  much 
higher  among  them  than  among  the  white  race.  These 
impressions  have  been  based  partly  upon  the  observations 
of  those  physicians  who  have  been  brought  in  professional 
contact  with  negroes,  and  partly  on  a  'priori  deductions  from 
the  generally  admitted  sexual  promiscuity  of  the  majority 
of  this  race.  Murrell,  of  Richmond,  Va.,  was  one  of  the 
first  to  call  attention  to  the  prevalence  of  syphilis  among  the 


86        THE  PREVALENCE  OF  SYPHILIS 

negroes  of  the  South.  Among  other  things  MurrelP^^  said: 
"MoraKty  among  these  people  is  almost  a  joke  and  is  only- 
assumed  as  a  matter  of  convenience,  or  when  there  is  a 
lack  of  desire  and  opportunity  for  indulgence,  and  venereal 
diseases  are  well-nigh  universal.  As  an  illustration  of  this, 
in  clinic  and  private  practice  I  have  never  seen  a  negro 
virgin  over  eighteen  years  of  age.  In  an  investigation  among 
negroes  of  all  classes  the  average  age  of  defloration  was  found 
to  be  about  fifteen,  and  these  estimates  are  not  unfair  to  the 
race  as  a  whole,  for  they  are  gained  from  experience  with  a 
part  of  the  negro  population  that  enjoys  exceptional  advan- 
tages for  education  and  improvement.  It  is  my  honest 
belief  that  another  fifty  years  will  find  an  unsyphilitic  negro 
a  freak  unless  some  such  procedure  as  vaccination  comes  to 
the  relief  of  the  race,  and  that  in  the  hands  of  a  compelling 
law.  Tuberculosis  is  often  spoken  of  as  the  scourge  of  the 
negro,  but  there  must  be  twenty  syphilitics  to  the  one 
consumptive,  and  hundreds  of  the  negro  consumptives  have 
syphilis  to  combat  as  well.  This  may  sound  exaggerated, 
but  it  is  near  the  pitiless  truth." 

Similar  evidence  as  to  the  sexual  habits  of  negroes  has 
been  given  by  Quillian,i-^  McHatton^'^*'  and  others.  Quillian 
states :  "  In  a  practice  of  sixteen  years  in  the  South  I  have 
never  examined  a  negro  virgin  over  fourteen  years  of  age. 
From  personal  observation  I  believe  that  from  60  to  70  per 
cent,  of  the  blacks  in  the  South  have  either  hereditary  or 
acquired  syphilis." 

Such  statements,  while  based  on  ample  clinical  experi- 
ence, are  obviously  guesses,  and  while  such  estimations  may 
not  exceed  the  facts  as  to  the  prevalence  of  syphilis  in  the 
negro  race  they  cannot  obviously  be  given  the  same  value 
as  accurate  statistical  investigations. 

Until  very  recently  no  such  accurate  statistics  have  been 
available.  Several  investigators  have  compared  the  admis- 
sion rates  for  syphilis  at  various  clinics  for  whites  and  negroes. 
Thus,  Matas,^^^  in  1896,  found  from  statistics  of  the  Charity 
Hospital  of  New  Orleans  that  for  the  ten  years  from  1884- 
1893  the  ratio  of  the  prevalence  of  syphilis  was  2.84  per  cent., 
or  28  cases  in  1000  for  the  whites,  and  5.06  per  cent.,  or  51 


STATISTICS  FROM  DIFFERENT  GROUPS  87 

cases  in  1000  among  the  colored.  That  is,  syphihs  was  nearly 
twice  as  frequent  among  the  negroes,  and  the  deaths  caused 
by  syphilis  were  exactly  three  times  greater  in  the  colored 
than  in  the  white  hospital  population.  FoXj^^e  jj^  1908, 
analyzed  statistics  based  on  Central  Dispensary  reports 
for  nine  years,  and  including  all  cases  of  syphilis  that  were 
treated  in  clinics  for  medicine,  surgery,  children,  gynecology, 
throat,  chest,  skin  and  genito-urinary  and  nervous  diseases. 
In  a  total  of  15,000  whites  included  there  were  621  cases  of 
syphilis,  while  in  a  total  of  32,000  blacks  there  were  roughly 
1900  cases  of  syphilis;  that  is,  that  syphilis  in  blacks  was 
only  1,46  times  as  frequent  as  in  whites.  According  to 
Hazen,^^^  Dr.  Warfield,  superintendent  of  the  Freedmen's 
Hospital,  Washington,  D.  C,  has  personally  tabulated  all 
cases  of  syphilis  in  the  service  of  that  hospital  from  1901- 
1912.  The  total  negro  patients  were  90,172,  having  4913 
cases  of  syphilis,  or  5.37  per  cent.  In  a  study  of  syphilis 
published  by  the  Committee  on  Social  Betterment  it  was 
found  that  in  the  hospitals  of  Washington  3.46  per  cent,  of 
all  patients  applied  for  treatment  because  of  syphilis.  A 
comparison  of  these  figures  shows  that  admissions  for 
syphilis  in  Washington  are  about  one  and  a  half  times  as 
frequent  among  negroes  as  among  whites.  These  figures 
agree  closely  with  those  of  Fox. 

Hazen^^"  has  also  reported  5  cases  of  syphilis  in  the  con- 
tagious stage  among  negro  children  attending  school,  and 
between  the  years  of  twelve  and  fifteen.  One  of  these,  a 
boy,  aged  fourteen  years,  gave  the  interesting  information 
that  three  boys  and  three  girls  of  his  school  had  formed  a 
"social  club"  and  had  had  intercourse  nearly  every  night, 
it  being  the  custom  to  change  the  partners  frequently. 
Hazen  quotes  Pollock  as  stating  that  each  year  in  Baltimore 
at  least  800  cases  of  venereal  disease  are  acquired  by  children 
under  fifteen  years  of  age.  In  general,  under  six  years  of 
age  more  cases  of  venereal  infection  occur  among  the  white 
children;  but  that  after  six  years  of  age,  when  sex  begins 
to  assert  itself,  there  are  more  cases  among  the  colored. 

Baetz^^^  states  that  at  Ancon  Hospital,  in  the  Canal  Zone, 
500  cases  of  syphilis  were  observed  among  8226  colored 


88  THE  PREVALENCE  OF  SYPHILIS 

admissions  during  a  period  of  twenty-three  months,  making 
6  per  cent,  of  colored  admissions  that  are  known  to  be  syphi- 
litic. Of  these  500  cases,  366,  or  4.4  per  cent.,  came  to  the 
hospital  solely  because  of  syphilis.  Such  figures,  which  might 
be  multiplied  indefinitely,  all  indicate  that  syphilis  is  more 
frequent  among  the  colored  race  than  among  whites.  They 
all  fail,  however,  to  give  any  adequate  idea  as  to  the  actual 
prevalence  of  syphilis  among  negroes  for  the  reason  that 
they  are  based  solely  on  admission  rates,  and,  as  all  the 
writers  quoted  have  observed,  the  negro  often  fails  to 
present  himself  for  treatment  for  syphilis  which  he  considers 
a  trifling  disorder,  and  when  he  does  consult  a  physician 
will  only  remain  under  treatment  for  a  few  days  or  weeks  until 
the  immediate  symptoms  have  passed  off.  Hazen  presents 
a  number  of  other  circumstances  and  figures  which  indicate 
that  syphilis  must  be  more  prevalent  among  negroes  than  the 
admissions  show.  Thus  the  health  reports  of  the  District 
of  Columbia  for  ten  years  ending  1903  show  that  during  this 
period  there  were  27,893  legitimate  and  907  illegitimate 
births  among  whites  and  13,909  legitimate  and  4786  illegiti- 
mate births  among  the  colored.  Practically  one-third  of  the 
population  was  negro.  In  a  study  of  2000  cases  of  skin 
diseases  in  negroes  and  a  similar  number  in  whites,  Hazen 
found  over  three  times  as  much  secondary  and  tertiary 
syphilis  in  the  negro,  nearly  six  times  as  many  gummas  and 
over  four  times  as  much  hereditary  syphilis  in  the  negro. 
The  average  age  of  infection  in  500  consecutive  cases  was 
twenty-one  years,  but  9  ckses  were  in  school  children,  4  of 
whom  were  under  fifteen  years  of  age. 

Lee^^^  says:  "Syphilis  has  as  much  to  do  with  the  high 
death-rate  in  the  negro  as  any  other  single  factor.  It  does 
not  show  on  the  death  certificate,  but  as  a  complication  of 
bronchitis,  pneumonia  and  tuberculosis  it  reduces  the  chance 
of  a  successful  fight  against  those  diseases,  and  as  a  cause  of 
arteriosclerosis,  endocarditis,  cerebral  hemorrhage,  nephritis 
and  stillbirths  it  seems  to  be  ever  present.  As  city  physician 
during  three  years  I  treated  1426  negroes,  486  of  whom  had 
syphilis  in  some  evident  form,  to  say  nothing  of  those  who 
came  to  me  with  minor  ailments  who  only  paid  one  or  two 


STATISTICS  FROM  DIFFERENT  GROUPS  89 

visits  but  in  whom  the  disease  was  latent  and  in  whom  I  did 
not  make  the  diagnosis.  I  personally  believe  that  more 
than  50  per  cent,  of  the  colored  race  suffer  with  this  disease, 
either  inherited  or  acquired." 

We  may  now  pass  to  certain  investigations  that  have  been 
undertaken  with  the  definite  purpose  of  determining  the 
amount  of  syphilis  in  negroes.  In  1914  Murrell^-^^  stated: 
"  In  our  dispensary  work  in  Richmond  we  make  the  Wasser- 
mann  test  in  negroes  as  a  routine  measure,  and  it  is  almost 
invariably  positive.  Of  all  specimens  taken  probably  75 
per  cent,  show  a  positive  Wassermann." 

jygyi34  reported  the  results  of  a  Wassermann  test  among 
the  negro  insane  at  Alabama.  The  test  was  performed  on 
every  case  in  the  asylum,  with  the  following  results:  357 
males  were  examined,  of  whom  90,  or  25  per  cent.,  were 
positive,  and  of  these  90  males,  48  showed  clinical  signs  of 
syphilis;  349  females  were  examined,  of  whom  102,  or  29 
per  cent.,  were  positive,  and  49  showed  clinical  signs  of 
syphilis. 

Hindman^^^  performed  a  routine  W^assermann  reaction  on 
all  patients  admitted  to  the  Georgia  State  Sanitarium  from 
January  to  November,  1915;  1194  patients  were  admitted, 
of  whom  420  white  males  gave  over  6  per  cent,  positive 
reactions,  351  white  females  gave  over  5  per  cent,  positive  reac- 
tions, 255  negro  males  gave  over  16  per  cent:  positive 
reactions  and  218  negro  females  gave  over  16  per  cent,  posi- 
tive reactions.  All  positive  reactions  recorded  were  clear- 
cut  complete  inhibition  of  hemolysis.  Hindman  also  states 
that  Dr.  Lynch,  Professor  of  Pathology  in  the  Medical 
College  of  South  Carolina,  permits  the  use  of  the  following 
conclusions  arrived  at  by  a  comparative  study  of  a  large 
number  of  negroes  with  the  aid  of  the  Wassermann  reaction : 

1.  Syphilis  occurs  in  from  50  to  60  per  cent,  of  the  major 
class  of  our  Southern  negroes. 

2.  It  is  more  frequent  in  the  women  than  in  the  men. 
Vedder  and  Hough, ''^  in  a  Wassermann  survey  of  the  insane 

at  the  Government  Hospital  for  the  Insane,  Washington, 
D.  C,  studied  93  colored  males,  of  whom  22,  or  23  per  cent., 
were  syphilitic,  and  63  colored  females,  of  whom  8,  or  12 


90        THE  PREVALENCE  OF  SYPHILIS 

per  cent.,  were  syphilitic.  This  lower  percentage  in  the 
females  is  not  to  be  taken  seriously,  owing  to  the  fact  that 
only  a  small  number  of  colored  females  were  in  the  asylum  at 
the  time  of  the  examination.  Wender^^^  in  a  later  study  in 
the  same  institution  found  that  of  106  colored  male  patients 
admitted  between  July  1,  1914,  and  June  30,  1915,  53,  or 
one-half,  were  infected  with  syphilis.  In  21  cases  the  rela- 
tion between  the  psychosis  and  the  syphilitic  infection  could 
not  be  determined,  but  32,  or  30.1  per  cent.,  suffered  from 
syphilitic  disease  of  the  central  nervous  system;  11  suffered 
from  cerebrospinal  syphilis,  while  21  cases,  or  18.86  per  cent., 
suffered  from  general  paralysis.  Wender  concludes  that 
these  findings  justify  the  conclusion  that  syphilis  is  prevalent 
to  a  marked  degree  in  the  colored  race. 

McNeiU^''  investigated  the  prevalence  of  syphilis  among 
the  negroes  of  the  city  of  Galveston.  The  majority  of  the 
negroes  studied  were  of  the  working  class  and  the  wives 
and  children  were  also  included  in  the  study.  Of  1200  adult 
negroes  fifteen  years  of  age  or  over  applying  at  clinics,  34 
per  cent,  gave  definitely  positive  reactions.  In  order  to 
determine  the  prevalence  of  the  disease  among  average 
healthy  negroes  200  such  cases  were  examined,  of  whom  24 
per  cent,  gave  a  positive  Wassermann.  McNeil's  conclusions 
were  as  follows : 

1.  The  incidence  of  syphilitic  infection  among  apparently 
healthy  adult  negroes  in  this  community  varies  between  25 
and  30  per  cent. 

2.  The  infection  is  largely  acquired,  since  it  is  much  lower 
in  incidence  among  children  under  the  age  of  puberty. 

3.  The  incidence  of  syphilitic  infection  among  sick  negroes 
is  considerably  higher  than  among  the  well,  averaging 
between  40  and  50  per  cent. 

4.  The  occurrence  of  syphilis  among  white  people  of  the 
same  social  class  as  negroes  would  seem  to  be  about  the  same 
as  among  the  negroes.  In  the  better  class  of  white  people  the 
occurrence  is  much  less,  while  in  the  best  classes  it  is  almost 
nil. 

5.  Syphilis  is  undoubtedly  one  of  the  chief  causes  of  death 
and  disease  among  the  negroes,  ranking  as  high  or  higher 


STATISTICS  FROM  DIFFERENT  GROUPS  91 

than  tuberculosis,  Bright's  disease  and  pellagra  which  are 
the  three  other  chief  causes  of  death  and  disability  among 
that  race  in  this  community. 

Wilson^^^  made  an  examination  of  young  colored  girls  in  a 
reformatory  institution.  They  were  of  an  average  age  of 
sixteen  years,  the  youngest  being  eleven  and  the  oldest 
twenty-one.  The  Wassermann  was  positive  in  6  out  of  76 
of  these  girls,  or  8  per  cent.,  while  several  others  had  had 
syphilis  and  had  been  treated.  There  was  a  discharge  from 
the  vagina  in  20  cases,  with  a  positive  finding  for  gonococci 
on  a  single  examination  in  8  cases.  A  marital  vagina  was 
found  in  all  cases.  The  lower  percentage  of  syphilis  detected 
in  these  cases  is  probably  due  to  the  youth  of  these  girls, 
but  the  findings  bear  out  the  statements  of  others  as  to  the 
average  age  of  defloration  among  colored  girls. 

Jamison  1^^  examined  1000  consecutive  negro  females  who 
were  medical  cases  seen  at  the  clinics  of  the  Charity  Hospital 
at  New  Orleans.  Of  these,  166,  or  16.6  per  cent.,  were  diag- 
nosed as  syphilis.  Syphilis  headed  the  list  of  diagnoses, 
tuberculosis  coming  next  and  malaria  third;  but  there  were 
twenty  times  as  many  cases  of  syphilis  as  of  malaria.  The 
Wassermann  reaction  was  performed  on  about  half  of  the 
cases  diagnosed  as  syphilis  and  was  positive  in  about  80  per 
cent,  of  these  cases,  but  no  attempt  was  made  to  perform  a 
routine  Wassermann  on  all  patients.  Had  this  been  done 
it  may  be  assumed  that  the  number  of  cases  detected  would 
have  been  very  greatly  increased.  Investigations  in  the 
United  States  army  indicate  that  when  about  3  per  cent,  of 
clinical  syphilis  is  present  in  a  group,  if  the  Wassermann 
reaction  is  applied,  from  18  to  20  per  cent,  may  be  detected. 
In  other  words,  in  a  given  group  there  is  at  least  five  times 
as  much  syphilis  as  is  indicated  by  the  number  of  cases  pre- 
senting obvious  lesions  alone.  On  this  basis  we  may  estimate 
that  at  least  80  per  cent,  of  these  negro  women  were  infected. 
It  must  be  emphasized  that  this  is  a  mere  estimate,  but 
Boas^^o  estimates  on  the  basis  of  army  statistics  that  syphilis 
is  about  two  and  a  half  times  as  frequent  in  negroes  as  in 
whites. 

Moore^^i  gives  some  figures  in  regard  to  the  incidence  of 


92  THE  PREVALENCE  OF  SYPHILIS 

hereditary  syphilis  among  negro  children  applying  at  a 
clinic  for  treatment.  The  clinical  records  of  807  consecutive 
admissions  showed  that  of  582  negro  infants  and  children, 
52,  or  8.9  per  cent.,  were  clinically  suffering  from  hereditary 
syphilis,  while  out  of  225  white  infants  and  children,  7,  or 
3.1  per  cent.,  were  syphilitic.  The  clinically  evident  cases 
of  hereditary  syphilis  were  2.9  times  as  frequent  among  the 
negroes  as  among  the  whites.  The  Wassermann  reaction 
was  not  applied,  and  Moore  states  that  "Our  figures  should 
be  accepted  as  an  underestimate  of  the  frequency  of  heredi- 
tary syphilis."  Between  1900  and  1910  the  increase  in 
population  among  the  whites  was  15  per  cent,  while  among 
the  negroes  it  was  only  11.2  per  cent. 

Canal  Zone. — Qualls^^^  reported  routine  Wassermann 
tests  on  981  white  males  in  the  surgical  wards  of  Ancon 
Hospital.  Of  these  136,  or  13.8  per  cent.,  gave  a  double- 
plus  reaction  while  12  more  gave  a  plus  reaction,  so  that  it 
may  be  concluded  that  at  least  15  per  cent,  of  these  patients 
were  syphilitic. 

A  routine  test  was  also  made  on  1198  colored  male  surgical 
cases:  297  of  these  patients  showed  active  symptoms  or 
gave  a  history  of  previous  syphilitic  infection,  and  of  these 
104  gave  a  double-plus  reaction.  Of  the  901  cases  showing  no 
clinical  evidence  of  syphilis  197  gave  a  double-plus  Wasser- 
mann. Counting  the  double-plus  reactions  alone,  25  per  cent, 
of  these  negroes  were  syphilitic,  but  if  the  Wassermann 
reaction  be  considered  in  conjunction  with  the  clinical  find- 
ings, 27  per  cent,  are  demonstrated  to  be  syphilitic,  with  a 
probability  that  40  per  cent,  are  syphilitic. 

My  own  investigations  confirm  the  results  obtained  by 
others  indicating  the  great  prevalence  of  syphilis  among 
negroes.  This  work  has  been  carried  on  continuously  from 
1913  to  1917  as  opportunity  afforded. 

Sick  and  Delinquent  Negroes. — A  study  was  made  of  the 
negroes  at  the  Washington  Asylum,  which  includes  a  jail  to 
which  vagrants  and  petty  thieves  are  sent,  and  a  free  hospital 
maintained  by  the  District  of  Columbia.  A  Wassermann 
survey  was  made,  including  all  negroes  in  the  institution  at 
the  time  and  all  admissions  during  the  period  of  the  examina- 


STATISTICS  FROM  DIFFERENT  GROUPS 


93 


tion,  no  selection  of  cases  being  made.     The  results  of  this 
survey  of  598  negroes  may  be  seen  in  the  following  table: 


Total 
examined. 

Double  plus. 

Plus. 

Plus-minus. 

Minus. 

No. 

Per 

cent. 

No. 

Per 
cent. 

No. 

Per 
cent. 

No. 

Per 
cent. 

Hospital,  male     . 
Hospital,  female  . 
Jail      .... 

267 
105 
226 

106 
45 
71 

39.70 
42.85 
31.40 

39 
22 
33 

14.60 
20.95 
14.60 

36 

14 
46 

13.48 
13.33 
20.30 

86 
24 
76 

32.21 
22.85 
33.60 

Total     .      .      . 

598 

222 

37.12 

94 

15.72 

96 

16.05 

186 

31.10 

At  the  time  the  specimens  of  blood  were  taken  a  brief 
history  was  also  obtained.  By  combining  the  results  of  this 
examination  with  the  Wassermann  reaction  the  following 
results  were  obtained: 


Total 
examined. 

Undoubted 
syphilitica. 

Doubtful. 

Negative. 

No. 

Per 

cent. 

No. 

Per 
cent. 

No. 

Per 
cent. 

Hospital,  male 
Hospital,  female     . 
Jail 

267 
105 
226 

150 
66 
97 

56.18 
62.85 
42.90 

65 
19 
69 

24.35 
18.09 
30.50 

52 
20 
60 

19.47 
19.04 
26.50 

Total        .... 

598 

313 

52.34 

153 

25.58 

132 

22.08 

It  is  evident  from  this  series  that  at  least  52  per  cent,  of 
all  the  598  inmates  of  this  institution  are  undoubtedly 
syphilitic,  and  further,  that  the  percentage  of  infections  was 
higher  among  the  women  than  among  the  men. 

Of  interest  in  this  connection  is  the  fact  that  in  this  series 
there  was  one  girl  of  fourteen  years  of  age  with  a  diagnosis 
of  condylomata  and  a  double-plus  Wassermann,  and  another 
girl  of  twelve  years  of  age  was  diagnosed  chancre  and  had  a 
double-plus  Wassermann.  This  undoubtedly  proves  that  in 
a  certain  percentage  of  cases,  sexual  irregularities  occur  at  a 
very  early  age  in  the  negro  race,  as  has  already  been  affirmed. 
It  would  be  exceedingly  difficult  to  match  these  cases  in 
children  from  the  white  race.  On  the  basis  of  all  the  facts 
it  is  estimated  that  from  60  to  70  per  cent,  of  the  negroes 
in  the  Washington  Asylum  were  infected  with  syphilis. 

A  routine  Wassermann  reaction  was  also  performed  on 


94 


THE  PREVALENCE  OF  SYPHILIS 


420  colored  women  from  the  gynecological  service  of  the 
Columbia  Hospital  for  Women.  The  results  of  this  examina- 
tion are  as  follows : 


Total 

Double  plus. 

Plus. 

Plus-minus. 

Negative. 

examined. 

No. 

Per 
cent. 

No. 

Per 
cent. 

No. 

Per 
cent. 

No. 

Per 

cent. 

420       ...       . 

105 

25 

52 

12.38 

46 

10.95 

217 

51.66 

Healthy  Negroes. — A  survey  was  made^^  on  1472  negro 
soldiers  from  two  regiments  stationed  at  four  different  posts. 
Of  these  men,  sixteen  were  on  the  sick  report  for  syphilis, 
and  a  Wassermann  test  was  made  on  the  remaining  1456  men, 
with  the  result  that  321,  or  22.04  per  cent.,  gave  a  double- 
plus  reaction;  193,  or  13.26  per  cent.,  gave  a  plus  reaction; 
162,  or  11.12  per  cent.,  gave  a  plus-minus  reaction,  780,  or 
53.57  per  cent.,  were  negative.  Including  the  double-plus 
cases  and  those  under  treatment  for  syphilis,  22.21  per  cent, 
were  found  to  be  syphilitic;  and  if  the  plus  cases  be  added,  the 
estimated  number  of  probable  syphilitics  may  be  placed  at 
36  per  cent.  This  is  to  be  compared  with  the  8.21  per  cent, 
of  undoubted  syphilitics  found  among  white  soldiers  by  the 
same  examination  and  the  16.08  per  cent,  of  estimated 
probable  syphilitics  among  white  soldiers. 

TABULATION    OF   RESULTS    OBTAINED    BY    THE   WRITER    FROM 
SURVEYS   IN    THE    ARMY   AND    PREVIOUSLY   PUBLISHED. ^^ 


m 

d 

'^^ 

TJ 

.2 

OS 

a 

1-i 

Survey. 

a 

2 

a  o 

S 

^3S 

II 
1  " 

nate    of 
mber  prob 
philitic, 
r  cent. 

&      fH 

o  a  tH 

^1 

■^ 

ss. 

T"a 

1&S. 

H 

M 

+ 

0 

+ 

W 

Recruits 

1019 

0 

7.75 

7.75 

9.02 

16.77 

Cadets        .... 

621 

0 

2.57 

2.67 

2.89 

6.46 

White  enlisted  men    . 

1677 

3.44 

4.77 

8.21 

7.87 

16.08 

Colored  enlisted  men 

1472 

1.08 

21.8 

22.21 

13.11 

36.00 

Porto  Rico  regiment 

531 

13.65 

28.58 

42.37 

13.66 

65.93 

Military  convicts 

1145 

6.48 

9.50 

15.98 

5.67 

21.65 

Insane  soldiers 

567 

3.51 

8.29 

11.80 

7.41 

19.21 

Tuberculous  soldiers 

229 

7.56 

15.72 

23.28 

15.72 

39.00 

Soldiers'  Home 

1171 

11.62 

13.40 

25.02 

9.73 

34.75 

Total 

8332 

STATISTICS  FROM  DIFFERENT  GROUPS 


95 


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96        THE  PREVALENCE  OF  SYPHILIS 

Healthy  Colored  Women. — These  figures  have  already  been 
given  but  may  be  recapitulated  here.  Of  a  total  of  662  such 
women  examined,  125,  or  18.88  per  cent.,  gave  a  double-plus 
reaction;  81,  or  12.23  per  cent.,  gave  a  plus  reaction;  70,  or 
10.57  per  cent.,  gave  a  plus-minus  reaction;  368,  or  58.30 
per  cent.,  gave  a  negative  reaction. 

From  this  statement  it  will  be  seen  that  the  writer  has 
personally  performed  over  15,000  Wassermann  reactions 
in  systematic  surveys  on  various  groups  of  the  army  and  of 
the  population  of  Washington,  D.  C.  Similar  surveys  have 
also  been  performed  on  39,116  consecutive  recruits  for  the 
army  by  other  medical  officers.  The  recent  literature  has 
also  been  studied  in  an  attempt  to  obtain  all  the  statistics 
that  would  be  of  value  in  determining  the  prevalence  of 
syphilis  in  the  various  groups  of  the  population.  This  work 
may  now  be  summarized  as  follows: 


SUMMARY. 

1.  Prostitutes. — The  percentage  of  syphilis  among  prosti- 
tutes as  indicated  by  a  physical  examination  or  a  positive 
Wassermann  reaction,  or  both,  is  as  follows:  51  per  cent. 
(Davis) ;  54.4  per  cent.  (Kneeland) ;  65.5  per  cent.  (Sullivan 
and  Spaulding) ;  67  per  cent.  (Walker) .  European  figures  are 
even  higher:  75  per  cent.  (Meirowsky);  73  per  cent.  (Hecht); 
78  to  81  per  cent.  (Pinkus);  100  per  cent.  (Browning).  As 
no  one  would  claim  that  all  cases  of  syphilis  are  detected  by 
this  examination,  these  must  be  regarded  as  minimal  figures, 
and  we  may  therefore  estimate  that  among  prostitutes  in 
the  United  States  syphilis  occurs  in  from  50  to  100  per  cent., 
depending  upon  circumstances,  particularly  upon  the  length 
•of  time  they  have  been  prostitutes. 

2.  The  Insane. — The  percentage  of  syphilis  among  insane, 
as  a  general  class,  as  indicated  by  a  physical  examination  or 
a  positive  Wassermann,  or  both,  is  15.8  per  cent,  in  Massa- 
chusetts (Southard);  18.1  per  cent,  in  Michigan;  20  per  cent, 
in  Oregon  (Matson) ;  20.4  per  cent,  in  Pennsylvania  (Darling 
and  Newcomb);  24.5  per  cent,  in  Massachusetts  (Paine). 


SUMMARY  97 

For  male  insane  the  following  figures  are  given: 
Louisiana,  8  per  cent.  (Holbrook);  Washington,  D.  C,  20 
per  cent.  (Vedder  and  Hough);  Michigan  State  Hospital, 
21.6  per  cent.;  Illinois,  22  per  cent.   (Fell);  Pennsylvania, 

22.3  per  cent.  (Mitchell);  Massachusetts,  25.4  per  cent. 
(Paine).  As  the  figures  given  by  Holbrook  are  ob\'iously 
too  low  they  may  be  disregarded,  and  we  may  conclude  that 
among  male  white  insane  syphilis  is  demonstrable  in  from 
20  to  25  per  cent.;  and  that  it  is  probably  present  in 
from  25  to  35  per  cent,  of  white  male  insane. 

For  female  white  insane  the  following  figures  are  given: 
Louisiana  4  per  cent.  (Holbrook);  Illinois,  9.5  per  cent. 
(Fell);  Michigan,  12.7  per  cent.;  Pennsylvania,  18.5  per  cent. 
(Mitchell);  Massachusetts,  23.1  per  cent.  (Paine).  We  may 
therefore  conclude  that  syphilis  is  demonstrable  in  from 
10  to  23  per  cent,  of  female  white  insane,  depending  upon 
the  locality  and  the  circumstances;  and  we  may  estimate 
that  sjT^hilis  is  probable  among  from  15  to  30  per  cent,  of  this 
class  of  patients. 

3.  Adult  Admissions  to  Hospitals  and  Dispensaries  for 
Medical  and  Surgical  Conditions. — The  percentage  of  sj^hilis 
among  such  adult  admissions  has  been  indicated  variously 
as  follows: 

New  York:  Greeley  estimated  20  per  cent.  The  Wasser- 
mann  reaction  on  6536  male  and  female  admissions  at 
Bellevue  gave  25.6  per  cent,  positives. 

Chicago:  20  per  cent.  (Gatewood);  18.6  per  cent.  (Moore). 

Michigan:  6  per  cent.  (Peterson;  W^assermann  alone); 
30  per  cent.  (Warthin;  treponemata  found  at  necropsy). 

Boston:  15  per  cent.  (Walker  and  Haller;  Wassermann); 

17.4  per  cent.  (Hornon;  Wassermann);  28.2  per  cent. 
(Bryan  and  Hooker;  W^assermann  and  clinical  examina- 
tion). 

San  Francisco:  6.9  per  cent.  (Whitney;  clinical  examina- 
tion with  partial  Wassermann). 

Baltimore:  20  per  cent.  (Major;  Wassermann);  10.8  per 
cent.  (Walker;  Wassermann);  13  per  cent.  (Jane way;  Wasser- 
mann). 

Philadelphia:  27.4  per  cent.  (Rosenberger;  Wassermann); 
7 


98         THE  PREVALENCE  OF  SYPHILIS 

14  per  cent.  (Musser;  Wassermann) ;  12  to  20  per  cent. 
(Williams  and  Kolmer;  Wassermann). 

Washington:  10  to  25  per  cent.  (Ladd;  Wassermann). 

The  percentage  to  be  found  in  a  given  hospital  depends 
upon  two  factors:  the  class  of  patients  admitted  and  the 
thoroughness  of  the  examination.  As  showing  the  influence 
of  the  class  of  patient,  we  may  take  the  Philadelphia  General 
Hospital,  where  most  of  the  admissions  come  from  the 
poorer  classes,  and  where  the  Wassermann  indicates  27.4 
per  cent,  as  compared  with  the  admissions  to  the  hospital 
of  the  University  of  Pennsylvania,  where  the  admissions 
come  from  a  better  class  and  where  the  Wassermann  shows 
14  per  cent.  In  regard  to  thoroughness  of  examination:  in 
Michigan  Peterson  found  but  6  per  cent,  on  a  Wassermann 
examination  alone,  but  Warthin,  after  a  careful  search  for 
treponemata,  found  30  per  cent,  in  a  hospital  where  the 
admissions  come  from  a  very  good  class  of  the  population. 
With  the  exception  of  Warthin's  figures  all  statistics  presented 
are  minimal.  In  consideration  of  the  fact  that  the  lower 
figures  quoted  would  have  been  very  greatly  increased  had  a 
complete  examination  been  made,  it  is  believed  that  it  is 
fair  to  estimate  that  between  20  and  30  per  cent,  of  the 
clientele  of  the  average  hospital  are  infected  with  syphilis. 

In  the  cases  admitted  to  the  general  medical  and  surgical 
wards  there  is  no  indication  that  the  proportion  of  syphilis 
is  lower  among  the  women  than  among  the  men.  Thus  the 
figures  from  the  Philadelphia  General  Hospital  furnished  by 
Rosenberger  show  23.6  per  cent,  positives  among  the  men 
and  35.9  per  cent,  positives  among  the  women.  The  figm-es 
from  Bellevue  show  that  out  of  4085  males  admitted  to  the 
medical  or  surgical  wards,  1106,  or  27  per  cent.,  gave  a  posi- 
tive reaction;  while  among  1752  females  admitted  to  the 
medical  or  surgical  wards,  475,  or  27.1  per  cent.,  gave  a 
positive  reaction.  Thus  while  the  percentage  of  syphilis 
among  the  women  of  the  community  as  a  whole  is 
undoubtedly  lower  than  among  the  men,  it  is  as  high  or 
higher  among  the  sick  women  as  among  sick  men. 

4.  Private  Patients. -^Comparatively  little  information  is 
obtainable  in  regard  to  private  patients.    Ladd  stated  that 


SUMMARY  99 

he  found  14.1  per  cent,  of  positive  reactions  among  his 
patients  in  Washington,  D.  C,  while  McLester,  in  Birming- 
ham, Ala.,  found  18.8  per  cent,  among  his  private  patients. 
In  neither  case  was  the  proportion  between  men  and  women 
given.  Among  the  better  class  of  private  patients  in  Wash- 
ington, Vedder  found  5.3  per  cent,  of  positive  Wassermann 
reactions  among  the  males  and  4  per  cent,  among  the  females. 
We  may  therefore  conclude  that  since  these  figures  are  all 
based  oh  Wassermann  surveys,  and  would  be  higher  with  a 
complete  examination,  that  it  is  a  conservative  estimate  that 
from  10  to  20  per  cent,  of  private  patients  are  infected  with 
syphilis,  the  exact  percentage  depending  largely  upon  the 
class  from  which  such  patients  are  drawn. 

5.  Tuberculosis. — The  prevalence  of  syphilis  among  the 
tuberculous  in  this  country  has  been  variously  placed  by 
different  investigators  on  the  basis  of  a  clinical  examination 
or  a  positive  Wassermann,  or  both.  Some  of  these  are  as 
follows:  Vedder,  23.2  per  cent.;  Snow  and  Cooper,  20  per 
cent.;  Petroff,  21.8  per  cent.;  Lyons,  9.2  per  cent.;  Jones, 
29  per  cent.  The  figures  given  by  Lyons  were  based  upon  a 
Wassermann  examination  alone,  and  are  so  low  as  to  tlirow 
some  doubt  upon  the  efficiency  of  the  reaction  used,  or  else 
the  investigation  must  have  been  made  upon  an  exceptionally 
good  class  of  patients.  On  the  basis  of  such  figures  it  is  fair 
to  estimate  that  from  20  to  30  per  cent,  of  the  ordinary  class 
of  consumptives  met  with  in  institutions  have  syphilis  as 
well  as  tuberculosis  to  contend  with.  The  importance  of 
syphilis  as  a  predisposing  cause  of  tuberculosis  must  be  given 
serious  consideration,  and  sanatoria  should  make  provision 
for  the  diagnosis  and  treatment  of  syphilis  if  they  wish  to 
give  their  tuberculous  patients  a  reasonable  chance  for 
recovery. 

6.  Sick  Children. — Churchill  and  Austin  estimate  that  the 
percentage  of  syphilis  among  children  sick  in  hospital  may 
range  from  2  to  14  per  cent.  In  their  own  series  it  was  3.3 
per  cent.  Whitney  gives  2.9  per  cent,  in  San  Francisco. 
Holt  found  6.1  per  cent.  In  the  large  cities  it  may  fairly  be 
estimated  that  the  percentage  among  sick  children  ranges 
between  3  and  10  per  cent.,  depending  upon  circumstances. 


100  THE  PREVALENCE  OF  SYPHILIS 

At  the  same  time  among  certain  groups  it  may  be  much 
higher,  as  Johnson  found  33.9  per  cent,  among  the  open-air 
schools  of  St.  Louis.  These  schools  were  provided  for  anemic 
children  who  were  not  sick  enough  to  be  in  hospital,  and 
Churchill  found  38  per  cent,  in  another  series.  Among 
institutions  for  mentally  backward  children  and  delinquent 
children  the  percentages  are  also  very  high.  Lucas  found 
31.5  per  cent.;  Anderson,  17  per  cent.;  Haines,  14.5  per  cent. 
Here  again  we  have  minimal  figures,  so  that  we  may  estimate 
that  among  the  mentally  backward  and  idiots  the  percentage 
of  syphilitic  infection  will  fluctuate  between  20  and  40. 
It  seems  probable  therefore  that  syphilis  is  one  of  the 
important  causes  in  the  production  of  feeble-mindedness  and 
idiocy. 

7.  Criminals. — ^\^edder  found  15.9  per  cent,  of  military  ^pris- 
oners definitely  syphilitic,  with  5.6  per  cent,  more  prob- 
ably infected.  Boudreau  gives  figures  for  Auburn  as  16.8 
per  cent,  for  male  and  33.8  per  cent,  for  female.  Kramer 
found  18.1  per  cent,  positive  in  the  Ohio  Penitentiary. 
Thomas  found  21  per  cent,  among  naval  prisoners  and 
Pollitzer  reported  35  per  cent,  positive  among  the  criminal 
degenerate  and  derelict  class  of  New  York.  From  these 
figures,  which  are  all  minimal,  we  may  estimate  that  among 
this  class  the  amount  of  syphilis  may  range  from  20  to  40 
per  cent.,  depending  upon  circumstances. 

8.  Presumably  Healthy  Men  of  the  Class  that  Enlist  in  the 
Army. — Hunger  found  between  1  and  2  per  cent,  of  syphilitic 
infections  among  men  of  this  class,  73  per  cent,  of  whom 
were  under  twenty-one  years  of  age,  and  the  majority  of 
whom  were  seventeen  years  of  age.  Vedder  found  that  the 
percentage  of  infections  increases  steadily,  with  advancing 
years,  as  follows:  eighteen  to  twenty-two,  10  per  cent.; 
twenty-three  to  twenty-seven,  16  per  cent.;  twenty-eight 
to  thirty-two,  20  per  cent.;  thirty-three  to  thirty-seven,  24 
per  cent. ;  thirty-eight  to  forty-one,  28  per  cent.  It  is  believed 
that  these  figures  indicate  approximately  the  prevalence  of 
syphilis  among  the  unmarried  men  of  this  class.  The 
younger  men  will  average  below  20  per  cent,  but  the  older 
men  will  average  more  than  20  per  cent.,  so  that  as  a  group 


SUMMARY  101 

it  is  probably  fair  to  estimate  a  prevalence  of  20  per  cent. 
This  group  includes  unskilled  labor  and  a  certain  percentage 
of  the  trades. 

9.  Among  men  from  better  families  or  who  have  received 
a  better  education  the  percentage  of  infections  is  much 
lower,  probably  varying  between  2  and  10  per  cent.,  depend- 
ing upon  age,  marital  condition  and  other  factors. 

10.  Presumably  Healthy  Women. — Surveys  of  pregnant 
women  who  were  presumably  healthy  have  been  collected 
from  various  maternity  hospitals,  and  may  be  summarized 
as  follows :  Losee  found  3  per  cent,  infected,  while  in  Belle vue 
nearly  14  per  cent,  had  a  positive  Wassermann.  Falls  and 
Moore  found  9.5  per  cent.,  while  8  per  cent,  of  my  cases  gave 
a  double-plus  reaction  and  17  per  cent,  a  double-plus  or  a 
plus  reaction.  We  may  therefore  estimate  that  among 
young  women  in  the  community  the  percentage  of  syphilitic 
infections  fluctuates  between  3  and  20  per  cent.,  depending 
upon  age,  marital  condition,  education  and  social  status. 
The  infection  is  rare  among  the  unmarried  girls  of  good 
character,  but  is  only  too  common  among  married  women 
whose  virtue  is  beyond  challenge.  The  deduction  is  obvious. 
As  among  men  the  proportion  of  infections  increases  as  we 
descend  in  the  social  scale. - 

11.  The  Prevalence  of  Syphilis  among  Negroes. — All  the 
evidence  indicates  that  syphilis  is  far  more  common  among 
negroes  than  among  whites,  and  that  it  is  even  more  frequent 
among  negro  women  than  among  negro  men.  We  may 
estimate  that  the  rates  for  the  colored  race  are  at  least 
double  those  for  the  white  race.  Syphilis  is  undoubtedly 
the  greatest  cause  of  death  and  disability  in  the  negro  race. 

In  conclusion  it  may  be  stated  that  the  writer  is  fully 
aware  of  the  dangers  and  fallacies  inherent  in  statistics  of 
this  type.  It  has  been  necessary  to  present  imperfect 
statistics  because  no  perfect  statistics  are  available.  While 
I  have  not  hesitated  to  draw  conclusions  from  statistics  that 
are  obviously  fragmentary,  I  shall  have  no  quarrel  with 
anyone  who  chooses  to  differ  with  these  conclusions.  They 
are  offered  for  what  they  may  be  worth. 

If  the  figures  presented  'fail  to  satisfy  the  scientific  critic 


102  THE  PREVALENCE  OF  SYPHILIS 

this  should  indicate  the  necessity  for  securing  more  complete 
statistics  by  means  of  improved  diagnoses  on  death  certifi- 
cates and  especially  by  means  of  a  more  general  application 
of  the  Wassermann  reaction.  When  this  work  was  planned 
it  was  hoped  that  many  institutions  would  cooperate,  but 
experience  has  shown  that  even  an  offer  to  perform  a  Wasser- 
mann reaction  free  of  charge,  provided  it  is  made  on  all 
admissions,  does  not  appeal  to  many  institutions.  All  are 
willing  to  send  occasional  cases,  but  few  hospitals  will  take 
the  trouble  to  send  a  routine  blood  specimen  in  all  cases,  and 
probably  the  patients  themselves  object  in  many  instances. 
Yet  the  test  has  proved  of  great  value  to  those  institutions 
that  have  adopted  it  as  a  matter  of  routine;  and  it  is  probable 
that  information  as  to  the  prevalence  of  syphilis  can  be 
obtained  in  no  other  way.  It  is  believed  that  well-conducted 
hospitals  should  perform  a  routine  Wassermann  on  all  cases 
admitted.  Many  hospitals  have  for  years  made  a  routine 
urinary  examination  an  essential  in  the  examination  of  the 
patient.  Positive  findings  with  a  routine  Wassermann 
would  be  much  more  frequent  and  more  important  in  diag- 
nosis, for  syphilis  is  the  great  masquerader. 

City  and  State  Boards  of  Health  should  also  take  up  this 
work.  Syphilis  is  one  of  the  largest,  if  not  the  largest,  problem 
in  public  health  work  today,  and  public  health  officials 
should  not  be  content  to  use  the  laboratory  facilities  which 
they  possess  merely  to  perform  the  Wassermann  reaction 
as  a  diagnostic  measure  in  selected  cases  only,  but  by 
instituting  large  surveys  should  make  a  real  endeavor  to 
determine  the  prevalence  of  the  disease  in  their  respective 
communities. 

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SUMMARY  103 

4.  Rabinowitsch :  Syphilis  und  Wassermannsche  Reaktion  bei  den 
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104  THE  PREVALENCE  OF  SYPHILIS 

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nigenanstalten  Wiirttembergs  auf  Grund  von  Blutuntersuchungen  mittels 
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25.  Lippmann:  Ueber  die  Beziehung  der  Idiotie  zur  Syphilis,  Deutsch. 
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26.  Dean:  An  Examination  of  the  Blood  Serum  of  Idiots  by  the  Was- 
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27.  Hubert:  Die  Bedeutung  der  Vorgeschichte,  des  Befundes  und  der 
Wassermannschen  Reaktion  fiir  die  Erkennung  der  Syphilitischen  Anstec- 
kung  in  den  breiteren  Volksschichten,  Miinchen.  med.  Wchnschr.,  1915, 
Ixii,  1314. 

28.  Aerztlicher  Verein  in  Frankfurt,  Miinchen.  med.  Wchnschr.,  1910,  Ivii, 
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1914,  Ixiii,  497. 

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32.  Calmette,  Breton  et  Couvreur:  Application  pratique  de  la  Reac- 
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SUMMARY  105 

45.  Mackenzie:  Syphilis  in  the  Causation  of  Insanity,  from  the  Fourth 
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106  THE  PREVALENCE  OF  SYPHILIS 

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78.  Warthin:  Persistence  of  Active  Lesions  and  Spirochetes  in  the 
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83.  Hammond:  Statistical  Studies  in  Syphilis  with  the  Wassermann 
Reaction,  etc..  Am.  Jour,  of  Insanity,  1913-1914,  Ixx,  107.     . 

84.  Van  der  Hoof:  Syphilis  as  a  Factor  in  the  Production  of  Cardio- 
vascular-renal Disease,  Southern  Med.  Jour.,  1917,  x,  100. 

85.  McLester:  The  Frequency  of  Unsuspected  Syphilis,  Jour.  Am.  Med. 
Assn.,  1916,  Ixvi,  2063. 

86.  Major:  The  Wassermann  Reaction  in  the  Johns  Hopkins  Hospital, 
Johns  Hopkins  Hosp.  B\ill.,  1913,  xxiv,  175. 

87.  Janeway:  Shattuck  Lecture,  The  Etiology  of  the  Diseases  of  the 
Circulatory  System,  Boston  Med.  and  Surg.  Jour.,  1916,  clxxiv,  925. _ 

88.  Walker:  Symposium  on  Syphilis,  Congress  of  American  Physicians 
and  Surgeons,  1916,  Jour.  Am.  Med.  Assn.,  1916,  Ixvi,  1740. 

89.  Krumbhaar  and  Montgomery:  Syphilis  in  the  Medical  Dispensary, 
Jour.  Am.  Med.  Assn.,  1914,  Ixii,  290. 

90.  Rosenberger:  Summary  of  the  Wassermann  Tests  Done  during 
1916  in  the  Philadelphia  General  Hospital,  New  York  Medical  Journal, 

1917,  cv,  1233. 

91.  Osier:     The  Campaign  against  Syphihs,  Lancet,  1917,  i,  790. 


SUMMARY  107 

92.  Williams  and  Kolmer:  The  Wassermann  Reaction  in  Gynecology, 
Am.  Jour.  Obstet.,  1916,  Ixxiv,  639. 

93.  Ladd:  One  Thousand  Wassermann  Reactions,  New  York  Med.  Jour., 

1916,  civ,  952. 

94.  Letulle,  Bergeron  and  Lepine:  The  Wassermann  Reaction  in  Pul- 
monary Tuberculosis,  Bvdl.  de  I'Acad.  de  med.  de  Paris,  1914,  Ixxi,  .596. 

95.  Vedder:  The  Prevalence  of  Syphilis  in  the  Army,  Bulletin  No.  8, 
W.  D.,  Office  of  the  Surgeon-General,  p.  60. 

96.  Snow  and  Cooper:  The  Wassermann  Reaction  in  its  Relation  to 
Tuberculosis,  Am.  Jour.  Med.  Sc,  1916,  clii,  185. 

97.  Lyons:  Contact  Points  between  Tuberculosis  and  Syphilis,  Boston 
Med.  and  Surg.  Jour.,  1916,  clxxv,  285. 

98.  Jones,  W.  R. :  The  Wassermann  Reaction  in  251  Tuberculous  Dis- 
pensary Cases,  Med.  Record,  1916,  xc,  418. 

99.  Petroff:  Serological  Studies  in  Tuberculosis,  Am.  Rev.  Tub.,  1917, 
i,  49. 

100.  Ford:  The  Wassermann  Reaction  and  Pulmonary  Tuberculosis, 
Med.  Record,  1917,  xcii,  678. 

101.  Note  in  the  New  York  Med.  Jour.,  under  Collectanea,  July  14, 

1917,  vol.  cvi. 

102.  Boudreau:  The  Syphilis  Problem  among  Confined  Criminals,  Med. 
Record,  1916,  xc,  981. 

103.  Kramer:  The  Prevalence  of  Syphilis  in  a  Penal  Institution,  Illinois 
Med.  Jour.,  1915,  xxviii,  279. 

104.  Thomas:  Results  of  Wassermann  and  Luetin  Tests  at  the  Naval 
Prison,  Portsmouth,  N.  H.,  Med.  Record,  1915,  Ixxxvii,  523. 

105.  Pollitzer:  Syphilis  in  Relation  to  Some  Social  Problems,  Am.  Jour. 
Obstet.,   1916,  Ixxiii,   857. 

106.  Churchill:  The  Wassermann  Reaction  in  Infants  and  Children, 
Tr.  Am.  Pediat.  Soc,  1912,  xxiv,  149. 

107.  Blackfan,  Nicholson  and  White:  A  Study  of  the  Wassermann 
Reaction  in  100  Infants,  Am.  Jour.  Dis.  Children,  1913,  vi,  162. 

108.  Holt:  The  Wassermann  Reaction  in  Hereditary  Syphilis  in  Con- 
genital Deformities  and  in  Various  other  Conditions  in  Infancy,  Am.  Jour. 
Dis.  Children,  1913,  vi,  166. 

109.  Churchill  and  Austin:  Frequency  of  Hereditary  Syphilis,  Am. 
Jour.  Dis.  Children,  1916,  xii,  355. 

110.  Johnson:  Serological  Examination  of  over  200  Children  from  the 
Open-air  Schools  of  St.  Louis,  Am.  Jour.  Syphilis,  1917,  i,  606. 

111.  Lucas:  The  Incidence  of  Syphilis  in  111  Consecutive  Children 
Examined  in  the  Out-patient  Department  of  the  Psychopathic  Hospital, 
Boston  Med.  and  Surg.  Jour.,  1913,  clxix,  423. 

112.  Anderson:  On  Certain  Irregularities  in  Mental  Defect  Demon- 
strable by  Mental  Tests  and  Suggesting  Special  Educative  Measures, 
Boston  Med.  and  Surg.  Jour.,  1913,  clxix,  421. 

113.  Haines,  T.  H.:  High-grade  Defectives  at  the  Psychopathic  Hos- 
pital during  1913,  Boston  Med.  and  Surg.  Jour.,  1914,  clxxi,  854. 

114.  Thomsen,  Boas,  Hjort  and  Leschly:  Eine  Untersuchung  der 
Schwachsinnigen,  Epileptiker,  Blinden  und  Taubstummen  Danemarks  mit 
Wassermann's  Reaktion,  Berl.  klin.  Wchnschr.,  1911,  xlviii,  891. 

115.  Haines,  T.  H.:  Incidence  of  Syphilis  among  Juvenile  Delinquents, 
Jour.  Am.  Med.  Assn.,  1916,  Ixvi,  102. 

116.  Note  on  the  report  presented  by  Dr.  Sessions  at  the  Conference 
on  the  Education  of  Delinquent,  Truant,  Backward  and  Dependent  Chil- 
dren, at  Baltimore,  May,  1915,  Social  Hygiene,  1916,  ii,  476. 


108  THE  PREVALENCE  OF  SYPHILIS 

117.  McKay;  Inherited  Syphilis  in  Feeble-mindedness,  Illinois  Med. 
Jour.,   1915,   xxviii,  281. 

118.  Moulton:  Wassermann  Test  on  600  Cases  of  Feeble-minded  at  the 
Minnesota  School  for  Feeble-minded  and  Colony  for  Epileptics,  Jour. 
Psychoasthenics,  1914,  xviii,  222. 

119.  Dawson:  Additional  Report  of  Wassermann  Tests,  Jour.  Psycho- 
asthenics, 1914,  xviii,  227. 

120.  Munger:  A  Wassermann  Survey  on  500  Apprentice  Seamen,  Naval 
Med.  Bull.,  October,  1916,  x,  642. 

121.  Williams:  The  Limitations  and  Possibilities  of  Prenatal  Care, 
Jour.  Am.  Med.  Assn.,  1915,  Ixiv,  95. 

122.  Commisky:  A  Preliminary  Report  of  the  Routine  Wassermann 
Reaction  in  Hospital  Obstetrics,  Am.  Jour.  Obstet.,  1916,  Ixxiii,  676. 

123.  Falls  and  Moore:  The  Value  of  the  Wassermann  Test  in  Pregnancy, 
Jour.  Am.  Med.  Assn.,  1916,  Ixvii,  574. 

\  124.  Murrell:     Syphilis  and  the  American  Negro,  Jour.  Am.  Med.  Assn.,, 
I&^IO,  liv,  846. 

^125.  Quillian :     Racial  Peculiarities  as  a  Cause  of  the  Prevalence  of  Syphilis 
in  Negroes,  Am.  Jour.  Dermat.  and  Genito-urinary  Dis.,  1906,  x,  277. 

f26.  McHatton:  The  Sexual  Status  of  the  Negro,  Past  and  Present, 
Am.  Jour.  Dermat.  and  Genito-urinary  Dis.,  1906,  x,  6. 

127.  Matas:  The  Surgical  Peculiarities  of  the  Negro,  Tr.  Am.  Surg. 
Assn.,  1896,  xiv,  483. 

128.  Fox:  Skin  Diseases  in  the  Negro,  Jour.  Cutan.  Dis.,  1908,  xxvi, 
67,  109. 

129.  Hazen:  Syphilis  in  the  American  Negro,  Jour.  Am.  Med.  Assn., 
1914,  Ixiii,  463. 

130.  Hazen:     Syphilis  among  School  Children,  Washington  Med.  Ann., 

1913,  xii,  223. 

131.  Baetz:     Syphilis  in  Colored  Canal  Laborers,  New  York  Med.  Jour., 

1914,  c,  820. 

^  Q  132.  Lee :     The  Negro   as  a  Problem  in  Public  Health  Charity,   Am.  ^ 
'4^our.  Public  Health,  1915,  v,  207. 

133.  Murrell:     DiscussiononSyphilis, Jour.  Am. Med.  Assn. ,1914, Ixiii,  565, 

134.  Ivey:  The  Wassermann  Reaction  among  the  Negro  Insane  of 
Alabama,   Med.  Record,   1913,  Ixxxiv,  712. 

135.  Hindman:  Syphilis  among  Insane  Negroes,  Am.  Jour.  Public 
Health,  1915,  v,  218. 

136.  Wender:  The  Role  of  Syphilis  in  the  Insane  Negro,  New  York  Med. 
Journal,  1916,  civ,  1286. 

137.  McNeil:  Syphilis  in  the  Southern  Negro,  Jour.  Am.  Med.  Assn., 
1916,  Ixvii,  1001. 

138.  Wilson:  Disease  in  Apparently  Healthy  Colored  Girls,  New  York 
Medical  Journal,  1916,  ciii,  585. 

139.  Jamison :  Certain  Phases  of  Syphilis  in  the  Negro  Female  from  the 
Stand-point  of  Medical  Diagnosis,  New  Orleans  Med.  and  Surg.  Jour., 
1916,  Ixix,  96. 

:     140.  Boas:     The    Relative  Prevalence  of    Syphilis   among    Negroes    and 
"Whites,  Social  Hygiene,  1915,  i,  610. 

141.  Moore:  Hereditary  Syphilis  in  the  Negro  Race,  Southern  Med. 
Jour..  1915,  viii,  946. 

142.  Knapp:  Th"^  Wassermann  Reaction  in  Four  Hundred  Cases  Inves- 
tigated by  Group  Study  Methods,  Am.  Jour.  Syph.,  1917,  1,  772. 

143.  Quails:  Some  Observations  on  Latent  or  Clinically  Inactive  Syphilis 
in  the  Canal  Zone,  Am.  Jour.  Syph.,  1917,  i,  712. 


CHAPTER   II. 

THE  SOURCES  OF  INFECTION  AND  TRANS- 
MISSION OF  SYPHILIS. 

Inasmuch  as  the  Treponema  pallidum  (Spirocheta 
pallida)  *  is  now  universally  accepted  as  the  cause  of  syphilis,  f 
the  etiology  of  the  disease  need  not  be  discussed  here.  From 
the  public  health  stand-point,  however,  it  is  most  important 
to  be  fully  informed  in  regard  to  the  various  methods  where- 
by this  organism  is  transmitted  from  patient  to  patient, 
since  the  only  way  in  which  we  can  hope  to  prevent  the  dis- 
ease is  to  close  these  various  avenues  of  infection. 

Fortunately  the  methods  whereby  syphilis  is  transmitted 
are  well  known,  owing  to  the  fact  that  they  have  been  care- 
fully observed  by  physicians  of  experience  who  have  con- 
tinued to  study  this  important  point  ever  since  the  disease 
was  first  clearly  recognized.  The  literature  on  this  subject 
is  therefore  enormous  and  no  attempt  will  be  made  here  to 
treat  it  exhaustively,  but  merely  to  indicate  the  sources  of 
infection  and  the  various  methods  of  transmission  briefly 
but  clearly  enough  to  form  a  sound  basis  for  the  recommenda- 
tion of  appropriate  sanitary  measures,  with  sufficient  refer- 
ences to  literature  to  enable  the  reader  to  verify  the  accuracy 
of  the  statements  made. 

*  Pusey  has  recently  suggested  (Jour.  Am.  Med.  Assn.,  November  25, 
1916,  Ixvii,  162)  that  as  the  great  majority  of  writers  have  designated 
this  organism  by  the  name  of  Spirocheta  paUida,  this  name  should  be 
generally  adopted.  This  argument  loses  sight  of  the  fact  that  zoological 
nomenclature  is  not  determined  by  usage  but  by  certain  definite  rules. 
A  discussion  of  this  point  in  terminology  by  Charles  Wardell  Stiles  will  be 
found  in  the  Jour.  Am.  Med.  Assn.,  January  6,  1917,  Ixviii,  57.  While 
admitting  that  there  may  be  a  difference  of  opinion  on  the  subject.  Stiles 
favored  the  use  of  the  term  Treponema  paUidum,  which  is  accordingly  used 
throughout  this  work. 

t  An  exception  may  be  made  in  the  case  of  McDonagh  (Biology  and  Treat- 
ment of  Venereal  Diseases,  Harrison  &  Sons,  London,  1915),  who  claims  that 
the  Treponema  pallidum  is  only  one  phase  in  the  life-cycle  of  the  Leukocy- 
tozoon  syphilidis,  the  organism  which  he  claims  is  the  cause  of  syphilis. 


no     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

This  subject  may  be  considered  from  two  different  view- 
points, namely,  (1)  the  sources  of  infection,  or  an  investiga- 
tion of  the  infectiousness  of  the  various  lesions  or  bodily  fluids 
with  which  direct  or  indirect  contact  is  possible,  and  (2) 
the  methods  of  transmission,  or  a  practical  study  and  classi- 
fication of  the  exact  methods  whereby  actual  cases  of  syphilis 
have  received  their  infection. 

THE  SOURCES  OF  INFECTION. 

Syphilis  cannot  be  transmitted  as  are  many  other  infectious 
diseases  by  means  of  infected  water,  food  or  air.  The  Tre- 
ponema pallidum  is  conveyed  from  patient  to  patient,  either 
by  direct  bodily  contact  or  by  contact  with  some  material 
object,  upon  which  infectious  secretions  have  been  deposited, 
and,  so  far  as  known,  syphilis  cannot  he  transmitted  in  any 
other  way.  Since  an  actual  transference  of  the  infecting 
organism  from  one  individual  to  another  is  necessary,  the 
most  important  evidence  bearing  on  the  sources  of  infection 
may  be  considered  under  the  following  heads: 

A.  Immediate  Bodily  Contact. — ^The  transmission  of  syphilis 
by  bodily  contact  depends  upon  the  infectiousness  of  the  vari- 
ous specific  lesions  with  which  bodily  contact  is  possible.  This 
infectiousness  depends  mainly  upon  whether  treponemata  are 
present  in  the  lesion  in  question,  and  if  so,  in  what  numbers. 

B.  Mediate  Infection.  —  So  far  as  mediate  infection  by 
various  objects  is  concerned,  it  is  necessary  to  determine: 

1.  The  infectiousness  of  the  various  bodily  fluids  which 
may  become  deposited  on  these  objects. 

2.  The  viability  of  the  Treponema  pallidum  outside  the 
body  or  its  ability  to  live  and  retain  its  infectious  properties 
when  deposited  on  these  objects  under  various  conditions. 

C.  The  Methods  Whereby  the  Treponema  Pallidum  Gains 
Access  to  the  Healthy  Body: 

1.  Penetrative  powers  of  the  Treponema  pallidum.  Can 
this  organism  penetrate  sound  skin  or  mucous  membrane, 
or  is  it  forced  to  gain  entrance  to  the  body  through  fissures? 

2.  Genitotropic  tendency  of  the  Treponema  pallidum. 

3.  Infection  d'emblee;  cryptogenic  infection. 


THE  SOURCES  OF  INFECTION  111 

In  the  following  discussion  we  will  endeavor  to  follow  this 
analysis. 

A.  The  Infectiousness  of  the  Various  Syphilitic  Lesions  with 
which  Bodily  Contact  is  Possible. — 1.  The  Frirnary  Lesion  or 
Chancre. — It  is  amply  demonstrated  that  the  chancre  is 
highly  infectious  from  its  first  appearance  until  it  is  com- 
pletely healed.  It  is  extraordinarily  rich  in  its  treponema 
content  and  the  chancre  juice  or  serrnn  obtained  by  pressure 
from  the  chancre  teems  with  Yixmg  organisms.  Treponemata 
haA"e  been  demonstrated  by  a  dark  field  examination  in 
chancres  of  only  two  or  three  days"  duration*  long  before 
the  sore  had  taken  on  the  clinical  appearance  of  a  chancre, 
and  while  it  resembled  a  simple  abrasion.  From  this  it  will 
be  seen  that  not  only  is  the  chancre  highly  infectious,  but  from 
the  nature  of  the  case  it  is  one  of  the  lesions  of  sj-phHis  most 
frequently  responsible  for  the  transmission  of  the  disease. 
The  chancre  is  usually  painless,  is  frequently  atypical  and 
apparently  a  trifling  lesion,  and  only  appears  from  four  to 
six  weeks  after  the  infection  was  received,  or  a  period  so 
long  that  the  average  person  has  ceased  to  consider  the 
probability  of  infection. 

From  all  of  these  chcmnstances  it  foUows  that  in  the 
absence  of  a  careful  daily  Inspection  a  chancre  may  exist 
for  many  days  before  it  is  detected.  It  is  comparatively  rare 
to  obtain  the  history  of  a  primary'  sore  from  women,  by  whom 
the  chancre  is  not  noticed,  owing  to  the  fact  that  an  Inspec- 
tion is  seldom  made,  and  m  addition  it  is  frequently  located 
Internally. 

Taking  all  of  these  facts  Into  consideration  it  will  be  seen 
that  sexual  intercourse  frequently  occurs  while  oue  of  the 
parties  suffers  from  a  highly  infectious  chancre.  Usually  the 
erdstence  of  the  chancre  is  unknown,  but  many  men  of  the 
lower  classes  pay  no  attention  to  such  smaU  matters.  I  ha^-e 
several  tunes  questioned  patients,  particularly  negroes,  who 
admitted  Intercourse  many  tunes  after  they  knew  of  the 
appearance  of  a  sore,  and  I  have  examined  a  yoimg  woman 
who  was  only  aljle  to  walk  with  difficidty  because  of  inguinal 

*  BuUetin  No.  8,  War  Department,  OflBce  of  the  Surgeon-General,  p.  10. 


112     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

adenitis,  and  who  had  a  large  chancre,  yet  was  continuing 
her  usual  sexual  relations.  Every  physician  has  undoubtedly 
had  similar  experiences.  In  the  case  of  the  woman  it  is  certain 
that  she  is  seldom  conscious  of  the  existence  of  a  chancre,  but 
in  any  case  prostitutes  are  almost  certain  to  continue  their 
vocation  during  the  entire  primary  stage  of  the  disease,  and 
thus  many  men  are  infected. 

2.  The  Secondary  Lesions. — Ricord^  denied  that  secondary 
lesions  were  contagious,  and  his  authority  was  so  great  that 
about  twenty  years  elapsed  before  the  infectiousness  of 
secondary  lesions  was  accepted.  Ricord  finally  became  con- 
vinced upon  this  point^  and  the  infectiousness  of  secondary 
lesions  was  generally  admitted,  but  the  period  during  which 
the  disease  might  be  transmitted  was  believed  to  be  about 
six  months.  This  period  was  gradually  lengthened  first  to 
one  year  and  soon  to  two,  and  a  little  later  to  three  and  four 
years  by  the  work  of  Langlebert,  Diday  and  Fournier.  The 
general  opinion  immediately  prior  to  1889  was  that  syphilis 
was  infectious  during  all  the  secondary  period,  which  was 
placed  at  from  three  to  four  years,  but  that  tertiary  lesions 
were  not  infectious. 

We  now  know  that  all  secondary  lesions  are  potentially 
infectious  because  treponemata  have  been  demonstrated 
in  all  of  them.  The  mucous  patch  is  the  secondary  lesion 
most  commonly  responsible  for  the  transmission  of  the  dis- 
ease. Like  the  chancre  it  fairly  teems  with  treponemata,  it  is 
comparatively  painless,  and  occurring  in  the  mouth  or  geni- 
talia it  occupies  the  two  regions  of  the  body  most  commonly 
brought  into  close  and  intimate  contact  with  persons  of  the 
opposite  sex. 

Since  the  lesions  of  the  secondary  stage  are  responsible  for 
most  of  the  infections  with  syphilis  it  is  important  to  deter- 
mine how  long  this  stage  may  last. 

Duration  of  the  Secondary  Stage. — We  have  already  men- 
tioned the  earlier  views  on  this  subject.  Hutchinson  stated 
in  1896  that  the  contagiousness  of  syphilis  did  not  as  a  rule 
last  more  than  two  years.  This  statement  is  altogether  too 
optimistic. 

The  ability  of  a  given  patient  to  transmit  infection  only 


THE  SOURCES  OF  INFECTION  113 

depends  upon  the  length  of  time  he  has  suffered  from  the 
disease  in  so  far  as  the  duration  of  the  infection  influences  the 
type  of  lesions.  Time  plays  no  part  when  it  is  a  question  of 
the  infectiousness  of  a  mucous  patch,  for  example,  which  is 
just  as  infectious  when  it  occurs  ten  years  after  the  chancre 
as  when  it  appears  two  months  after  the  primary  lesion. 
The  point  to  determine,  therefore,  is  the  possible  duration  of 
the  secondary  lesions,  or  the  period  of  inflammatory  vascular 
phenomena.  So  long  as  exudative  papules  are  present  infec- 
tion is  possible.  Buba^  has  reviewed  the  literature  on  this 
subject,  which  may  be  condensed  as  follows:  Buba  quotes  a 
case  from  the  clinic  of  Dr.  Max  Joseph,  in  which  a  man  who 
had  had  a  chancre  eight  years  previously  married  and  infected 
his  wife.  The  man  had  mucous  patches  at  the  time.  Finger* 
relates  the  case  of  a  man  who  acquired  lues  in  1888  and 
married  in  June,  1896.  He  had  had  specific  treatment.  His 
wife  developed  a  chancre  on  October  5,  followed  by  second- 
aries, and  when  examined  the  man  was  found  to  have  papules 
on  the  glans  and  skin  of  the  penis. 

Barthelemy^  found  that  of  531  prostitutes  at  St.  Lazare 
whose  infection  dated  from  four  to  twelve  years  back,  20 
had  papulomucous  syphilides.  All  had  had  irregular  or 
no  treatment.  Feulard*^  published  20  cases  at  the  London 
Congress,  in  which  infection  with  syphilis  had  been  trans- 
mitted sixteen  times  from  four  and  a  half  to  ten  years  after 
the  original  infection  and  four  times,  fourteen,  seventeen, 
eighteen  and  twenty  years  after.  Infection  in  these  cases 
for  the  most  part  was  caused  by  erosions  in  the  mouth  or 
genitalia,  but  2  of  these  cases  were  caused  by  ulcerating 
tertiary  syphilides.  Newman'^  reports  a  case  in  which  second- 
ary symptoms  occurred  from  ten  to  twenty  years  after  the 
primary  infection,  and  states  that  in  41  cases  the  secondary 
period  lasted  from  a  few  months  to  fourteen  years.  Tarasse- 
witch^  claims  that  the  secondary  stage  with  its  endless  lesions 
may  last  from  twenty-three  to  twenty-nine  years.  Kromayer^ 
relates  a  case  in  which  a  man  infected  in  1867  married  in 
1878  and  had  three  healthy  children,  but  infected  his  wife  in 
1896,  practically  thirty  years  after  receiving  his  infection. 
Tschistjakow^"  has  published  valuable  statistics  concerning 
8 


114    INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

the  length  of  the  condylomatous  secondary  period.  He  col- 
lected 1000  cases  from  the  clientele  of  Tarnowski  that  were 
observed  on  the  average  for  ten  years.  In  these  cases  the  last 
condylomatous  lesions  developed: 

Within  the  first  five  years  in  802  persons. 

Within  the  second  five  years  in  167  persons. 

Within  the  third  five  years  in  26  persons. 

Within  the  fourth  five  years  in  5  persons. 
From  these  facts  we  conclude  that,  as  a  general  rule,  the 
older  the  infection  the  less  frequent  are  the  secondary  mani- 
festations of  the  disease.  But  there  are  so  many  exceptions 
to  this  rule  that  in  the  individual  uncured  case  it  is  practically 
impossible  to  place  any  time  limit  on  the  appearance  of 
secondary  lesions.  And  as  not  only  these  late  secondary 
lesions  but  also  the  tertiary  lesions  may  transmit  infection, 
we  must  regard  any  uncured  syphilitic  as  a  possible  source 
of  infection,  although  it  is  probable  that  the  majority  of 
infections  are  acquired  from  syphilitics  in  the  primary  or 
early  secondary  stages  of  the  disease.  These  apparently  dry 
facts  become  of  interest  in  the  discussion  of  the  time  limit 
at  which  it  is  safe  to  permit  syphilitics  to  marry. 

3.  The  Tertiary  Lesions. — It  was  thought  for  many  years 
that  the  tertiary  lesions  of  syphilis  were  not  infectious.  In 
1889,  at  the  first  International  Congress  on  Dermatology 
and  Syphilis,  at  Paris,  the  question  of  the  infectiousness  of 
tertiary  lesions  was  raised  by  Landouzy.^^  In  this  paper 
Landouzy  quoted  a  case  of  conjugal  syphilis  in  which  the 
husband  infected  the  wife  from  an  undoubted  tertiary  lesion 
of  the  penis  occurring  twenty  years  after  the  original  infection. 
Fournier,^^  at  the  same  Congress,  related  a  case  of  a  husband 
having  a  tertiary  glossitis  fifteen  years  after  his  chancre,  and 
infecting  his  wife,  who  suffered  from  a  labial  chancre.  The 
question  was  raised  again  at  a  later  meeting  of  the  same 
society  in  1896,  at  which  Feulard  presented  the  case  of  a  man 
who  infected  his  wife  by  means  of  a  gumma  of  the  penis 
occurring  fourteen  years  after  the  primary  lesion.  Lassar^^ 
also  related  several  such  instances.  Zedlewski  (quoted  by 
Buba)  has  collected  5  similar  cases  in  his  inaugural  disserta- 
tion.    In  all  of  these  cases  infection  was  transmitted  from 


THE  SOURCES  OF  INFECTION  115 

gummata  on  the  penis  that  developed  from  eight  to  twenty 
years  after  the  chancre.  The  infectiousness  of  tertiary  lesions 
are  summed  up  so  far  as  clinical  evidence  is  concerned  by 
Tarassewitch^  in  1897,  who  concludes  that  the  numerous 
cases  in  which  husbands  have  infected  their  wives  from 
undoubted  tertiary  lesions  dating  from  fourteen  to  twenty- 
one  years  after  the  chancre,  and  under  conditions  that 
eliminate  other  modes  of  infection,  force  us  to  believe 
that  tertiary  lesions  may  prove  infective.  It  has  there- 
fore been  demonstrated  by  clinical  experience  that  ter- 
tiary lesions  may  prove  infectious.  When  the  Treponema 
pallidum  was  discovered  and  search  for  this  organism 
was  instituted  by  many  investigators  the  earlier  observers 
failed  to  find  the  parasite  in  tertiary  lesions.  However, 
later  and  more  careful  observations  have  demonstrated 
beyond  cavil  that  practically  all  tertiary  lesions  contain 
treponemata,  though  usually  in  such  small  numbers  that  they 
can  only  be  detected  after  a  most  thorough  search.  Doutrele- 
pont  and  Grouven^^  and  Tomasezewski^^  succeeded  in  finding 
the  typical  forms  of  the  pallida  in  gummas  and  other  tertiary 
lesions,  but  today  the  finding  of  the  offending  organism  in 
tertiary  lesions  is  so  common  that  it  excites  no  comment. 

Moreover,  the  presence  of  treponemata  in  these  lesions  was 
demonstrated  by  animal  inoculation.  Finger ^^  succeeded  twice 
in  infecting  apes  from  gummata.  With  all  clinical  and  ex- 
perimental evidence  in  accord  on  this  point,  infection  from  "any 
superficial  tertiary  lesion  must  be  considered  as  a  possibility. 

Practically  the  cases  of  infection  from  tertiary  lesions  are 
comparatively  rare,  though  by  no  means  exceptional.  There 
are  two  obvious  reasons  why  transmission  of  syphilis  from 
tertiary  lesions  is  comparatively  infrequent :  one  is  the  relative 
rarity  of  treponemata  in  such  lesions,  and  the  second  is  the 
pronounced  tendency  for  such  tertiary  lesions  to  become  local- 
ized in  the  internal  organs.  There  is  obviously  no  opportunity 
for  transmission  of  treponemata  from  such  internal  lesions 
except  under  the  most  unusual  circumstances.  But  tertiary 
eruptions  of  the  skin  and  superficial  gummatous  ulcerations 
are  by  no  means  uncommon,  and  from  the  sanitary  point  of 
view  must  be  regarded  as  potential  sources 'of  infection. 


116     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

B.  Mediate  Infection. — 1.  The  Infectiousness  of  the  Various 
Bodily  Fluids. — Blood. — Investigation  of  the  circulating  blood 
by  direct  microscopic  examination  is  generally  attended  with 
negative  results,  and  numerous  observers  have  failed  to  find 
treponemata  under  these  circumstances.  On  the  other  hand, 
a  few  observers  have  reported  that  they  have  found  the 
organism  by  microscopic  examination  of  blood  taken  from  a 
vein  by  puncture  through  sound  skin  (Neisser,^^  p.  71).  It 
is  evident  that  in  examinations  of  such  a  character,  and 
granting  the  reliability  of  the  investigator,  a  positive  finding 
outweighs  many  negative  findings  and  indicates  that  the 
organisms  are  undoubtedly  present  in  the  blood  stream. 
Even  the  successful  observers,  however,  have  only  succeeded 
in  finding  perhaps  a  single  treponema  in  a  small  number  of 
the  cases  investigated. 

Inoculation  experiments  have  been  more  successful, 
though  there  were  many  failures  among  the  earlier  experi- 
ments. Thus  Neisser"  and  Finger  and  Landsteiner^*^  both 
failed,  but  Hoffman^^  succeeded  three  times  in  producing 
syphilis  in  animals  by  the  inoculation  of  blood  taken  from 
cases  of  syphilis  of  a  duration  of  six  weeks,  three  months  and 
six  months  respectively.  Uhlenhuth  and  Mulzer^^  have  made 
a  long  series  of  inoculations  of  blood  from  patients  in  all 
stages  of  syphilis,  and  their  work  may  be  briefly  summarized 
as  follows :  The  blood  was  collected  from  a  vein,  defibrinated, 
and  from  1  to  2  c.c.  were  injected  into  the  testicles  of  rabbits 
within  ten  minutes  after  withdrawal  from  the  patient.  The 
blood  from  23  cases  having  a  chancre  with  or  without  the 
characteristic  inguinal  adenitis  was  tested.  Of  these  23  cases 
4  are  excluded  because  the  rabbits  died  within  the  incubation 
period  of  the  chancre.  Among  the  19  cases  in  which  at  least 
one  rabbit  lived  longer  than  four  months  a  positive  result 
was  obtained  in  16  cases,  or  84.2  per  cent.  A  positive  result 
means  the  development  of  a  syphilitic  lesion  in  the  testicle  of 
the  rabbit  in  which  living  treponemata  could  be  demonstrated. 
The  blood  of  38  patients  having  different  clinical  manifes- 
tations of  secondary  syphilis  (exanthemata,  polyadenitis, 
lesions  of  the  mucous  membranes  and  a  positive  Wassermann) 
were  examined  in  a  similar  manner.    Of  the  36  cases  in  which 


THE  SOURCES  OF  INFECTION  117 

the  experiment  was  satisfactory  a  positive  inoculation  was 
obtained  in  27  cases,  or  75  per  cent.  From  this  it  will  be  seen 
that  of  55  cases  in  the  primary  or  secondary  stage  of  syphilis, 
treponemata  were  demonstrated  by  inoculation  in  78.1  per 
cent.  The  bloods  of  only  4  cases  of  tertiary  syphilis  were 
tested.  A  positive  result  was  obtained  in  1  case,  the  patient 
having  a  gumma  of  the  tongue  and  a  positive  Wassermann. 
The  bloods  of  4  cases  of  so-called  latent  syphilis  were  tested 
and  a  successful  inoculation  in  the  rabbit  was  obtained  once. 

From  the  above  experiments  it  will  be  seen  that  the  infec- 
tiousness of  the  blood  has  been  demonstrated  in  all  stages 
of  syphilis.  The  blood  of  syphilitics  must  therefore  be 
regarded  as  capable  of  transmitting  the  disease,  although 
the  degree  of  infectiousness  is  evidently  much  higher  in 
the  case  of  blood  from  the  primary  and  secondary  stages 
than  in  the  tertiary  and  latent  cases.  The  blood  is  never 
so  highly  infectious  as  are  the  secretions  from  the  chancre 
or  mucous  patches.  These  latter  fairly  teem  with  trepone- 
mata while  the  number  in  the  blood  even  of  active 
secondary  syphilis  must  be  comparatively  small  as  indicated 
by  the  difficulty  in  detecting  them  by  direct  microscopic 
examination  and  by  the  fact  that  comparatively  large 
amounts  of  blood,  1  or  2  c.c,  are  necessary  in  order  to 
produce  successful  inoculations  in  animals. 

While  in  practice  blood  must  undoubtedly  be  considered 
infectious,  particularly  in  recent  cases,  it  is  not  highly 
infectious.  Moreover,  contact  with  fresh  blood  is  compara- 
tively infrequent,  so  that  the  danger  of  infection  from  this 
source  is  slight.  An  exception  to  this  statement  is  to  be  noted 
in  the  case  of  surgeons,  physicians,  nurses,  dentists  and  mid- 
wives.  Infections  from  syphilitic  blood  are  known  to  have 
occurred  often  enough  among  attendants  on  the  sick  to 
make  it  a  matter  of  importance  that  such  persons  should  be 
particularly  careful  to  protect  themselves  from  this  possible 
source  of  infection. 

Milk. — In  1876  Voss^"  noted  several  cases  in  which  a  wet- 
nurse,  who  had  no  symptoms  of  syphilis  at  the  time,  neverthe- 
less infected  a  healthy  child.  This  led  him  to  test  the  infec- 
tiousness of  milk.     He  obtained  milk  from  the  breast  of  a 


118     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

woman  suffering  from  secondary  syphilis  and  injected  this 
milk  into  three  young  prostitutes  with  their  consent.  The 
first  girl  injected  had  had  syphilis  and  the  result,  of  course, 
was  negative.  The  other  two  were  believed  never  to  have  had 
syphilis  because  they  had  been  under  observation  for  several 
years.  Of  these  two  experiments  one  was  negative  but  in 
the  second  girl  the  area  surrounding  the  injection  became 
indurated  and  the  neighboring  lymphatic  glands  were  also 
greatly  enlarged  and  indurated,  and  she  developed  secondary 
syphilis  forty  days  after  the  inoculation.  While  in  all  prob- 
ability this  resulted  from  the  inoculation  of  the  milk,  this 
experiment  cannot  be  accepted  unreservedly  because  of  the 
possibility  that  the  woman  may  have  contracted  syphilis 
in  some  other  way. 

Animal  experiments  are  not  open  to  this  objection.  Finger 
and  Landsteiner^*^  failed  in  one  case  to  produce  syphilis  in 
animals  by  inoculating  milk  from  a  syphilitic  woman,  but 
Uhlenhuth  and  Mulzer^^  have  succeeded  twice  out  of  eight 
attempts.  In  one  case  the  woman  had  no  clinical  symptoms 
of  syphilis  herself  but  had  given  birth  to  a  congenitally 
syphilitic  child  and  had  had  a  positive  Wassermann.  It  may 
be  noted  in  passing  that  it  is  such  cases  that  have  caused  the 
downfall  of  the  so-called  laws  of  Colles  and  Profeta.  The 
second  case  was  a  woman  having  the  clinical  manifestations 
of  fresh  secondary  syphilis. 

As  a  result  of  these  experiments  the  milk  of  a  syphilitic 
woman  must  be  regarded  as  infectious,  and  this  is  borne  out 
by  clinical  experience,  since  it  is  well  known  that  a  syphilitic 
wet-nurse  will  almost  surely  infect  a  healthy  child,  and  in  the 
absence  of  syphilitic  lesions  the  disease  would  appear  to  be 
transmitted  through  the  milk. 

Sputum,  Sweat  and  Urine. — Comparatively  little  is  known 
concerning  these  secretions,  and  they  are  not  generally 
regarded  as  infectious.  Uhlenhuth  and  Mulzer  have  inocu- 
lated the  urine  once  and  the  sputum  once  into  rabbits,  with 
negative  results.  On  the  other  hand,  Dreyer  and  ToepfeP^ 
demonstrated  the  presence  of  Treponema  pallidum  on  several 
occasions  in  the  urine  from  a  case  of  secondary  syphilitic 
nephritis.    In  one  of  these  instances  the  urine  was  withdrawn 


THE  SOURCES  OF  INFECTION  119 

by  a  catheter  and  the  identification  of  the  treponema  was 
confirmed  by  Schaudinn.  Pasini'^  investigated  the  organs 
of  children  suffering  from  congenital  syphilis  and  found 
Treponema  pallidum  in  the  lungs,  spleen,  liver  and  kidneys. 
This  finding  was  not  new,  as  Levaditi  in  France,  Buschke 
and  Fischer  in  Germany  and  Berterelli,  Volpino  and  Rodaeli 
in  Italy  had  already  demonstrated  this  parasite  in  the  lungs 
and  kidneys  of  children  having  congenital  syphilis. 

But  Pasini  claimed  to  have  found  numerous  treponemata 
in  the  epithelial  cells  of  the  pulmonary  alveoli,  the  bronchi, 
sweat  glands  and  the  tubules  of  the  kidney.  From  this 
observation  he  concluded  that  the  Treponema  pallidum  is 
eliminated  in  the  sputum,  sweat  and  m-ine,  and  that  therefore 
these  secretions  from  individuals  having  congenital  syphilis 
must  be  regarded  as  possibly  infectious.  Hoffman^^  states: 
"Inside  the  tissues  the  Treponema  pallidum  is  ordinarily 
extracellular,  being  found  in  the  lymph  spaces  and  in  the 
connective  tissue.  It  is,  however,  found  inside  of  parenchyma- 
tous cells,  connective-tissue  cells  and  leukocytes." 

It  seems  clear  that  if  this  organism  can  penetrate  into 
epithelial  cells  of  such  organs  as  the  lungs,  kidneys  and 
sweat  glands  that  it  may  be  assumed  a  priori  that  it  can 
also  pass  through  these  cells  and  enter  the  secretions  from 
these  organs.  It  is  generally  believed  that  these  secretions 
are  not  infectious,  but  in  view  of  the  above  findings  it  would 
appear  that  these  secretions  must  be  considered  as  possible, 
though  certainly  rare  sources  of  infection. 

It  is,  of  course,  understood  that  the  saliva  from  an  indi- 
vidual having  mucous  patches  in  the  mouth  is  infectious  to  a 
high  degree,  but  this  has  no  bearing  on  the  above  argument. 
In  the  latter  instance  the  source  of  infection  is  in  reality  the  « 
mucous  patch  and  not  the  glandular  secretion.  In  practice, 
however,  owing  to  the  frequent  presence  of  mucous  patches 
in  the  mouth,  the  saliva  of  syphilitics  must  always  be  regarded 
as  a  possible  source  of  infection.  The  same  may  be  said  of 
the  nasal  secretion  of  syphilitics  and  particularly  of  children 
suffering  from  congenital  syphilis. 

The  Spinal  Fluid. — Much  experimental  work  has  been 
performed  with  this  fluid,  and  it  has  been  definitely  proved 


120    INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

to  be  infectious  in  many  cases  in  which  the  central  nervous 
system  is  involved.  But  since  there  is  practically  no  pos- 
sibility for  the  transfer  of  this  fluid  from  one  individual  to 
another  it  can  play  no  part  in  the  transmission  of  syphilis 
except  in  so  far  as  doctors  and  nurses  might  become  acci- 
dentally infected  in  careless  handling  of  fluids  removed  by 
tapping  from  syphilitics.  These  fluids  are  used  in  the  Wasser- 
mann  reaction  without  inactivation,  and  several  instances 
are  known  in  which  such  fluids  have  been  accidentally  sucked 
into  the  mouth  through  a  pipette;  but  so  far  as  known  no 
case  of  infection  with  spinal  fluid  has  been  recorded. 

Spermatic  Fluid. — Neisser^^  has  reviewed  this  subject  up 
to  1911.  Neisser  himself  failed  to  infect  monkeys  in  seven 
trials  with  fresh  seminal  fluid  from  cases  in  various  stages 
of  the  disease.  Hoffmann  failed  in  three  trials  with  fluid  from 
cases  of  two  and  a  half  months,  eleven  months  and  eighteen 
months'  duration.  Finger  and  Landsteiner^^  succeeded 
twice  in  obtaining  a  positive  result.  One  of  these  success- 
ful inoculations  was  performed  with  the  spermatic  fluid  of  a 
patient  with  florid  secondary  syphilis.  The  fluid  was  obtained 
by  expression  from  the  seminal  vesicles,  and  microscopically 
was  normal  sperm  without  admixture  of  blood.  The  authors 
considered  that  any  admixture  of  material  from  the  syphilitic 
eruption  was  absolutely  excluded.  The  second  successful 
inoculation  was  performed  with  the  spermatic  fluid  of  a 
patient  who  had  syphilis  for  three  years  and  sufl^ered  from  a 
bilateral  interstitial  orchitis.  Uhlenhuth  and  Mulzer^^ 
confirmed  this  observation  in  1913.  They  obtained  seminal 
fluid  from  an  early  case,  with  relapse  after  salvarsan,  and 
successfully  inoculated  three  rabbits.  Seminal  fluid  from 
the  same  case  after  treatment  failed  to  infect  rabbits. 
Nichols^^  succeeded  in  flnding  a  typical  Treponema  pallidum 
by  means  of  dark-field  illumination  in  the  apparently  normal 
prostatic  fluid  of  a  secondary  case,  a  finding  that  I  was 
fortunate  enough  to  be  able  to  observe. 

Warthin^^  found  lesions  of  syphilis  in  the  testes  in  31  out 
of  36  male  syphilitics  at  autopsy.  The  lesion  most  often 
found  is  the  so-called  orchitis  fibrosa  syphilitica  chronica. 
Warthin  says:     "Spirochetes  are  found  in  these  areas,  and 


THE  SOURCES  OF  INFECTION  121 

the  close  relationship  of  the  spirochete  to  the  seminiferous 
tubules  makes  the  entrance  of  the  organism  into  the  tubule  a 
very  probable  occurrence,  and  can  be  taken  as  a  very  strong 
argument  for  the  possibility  of  seminal  infection.  In  con- 
genital syphilis  and  in  early  acquired  syphilis  I  have  found 
the  testes  swarming  with  spirochetes  even  when  no  histo- 
logical changes  can  be  recognized  in  the  organ.  In  such 
cases  great  numbers  of  spirochetes  must  gain  entrance  to 
the  tubules  and  pass  out  with  the  semen." 

Such  findings  demonstrate  that  the  seminal  fluid  from 
many  secondary  cases  is  infectious,  and  we  may  assume 
that  the  seminal  fluid  from  tertiary  cases  may  be  infectious 
in  the  presence  of  a  suitable  lesion  in  the  testicles. 

Clinical  experience  indicates  that  some  cases  of  syphilis 
appear  to  be  transmitted  through  inoculation  with  seminal 
fluid.  When  we  consider  the  great  number  of  cases  in  which 
husbands  have  infected  their  wives,  though  they  thought 
they  were  cured  previous  to  marriage  and  apparently  had 
suffered  from  no  perceptible  lesion  for  years,  we  are  led  to 
the  conclusion  that  the  infection  has  been  transmitted  by 
means  of  the  spermatic  fluid.  Fournier  and  other  great 
syphilologists  have  insisted  that  women  were  thus  infected 
at  the  time  of  conception  through  the  fetus  and  developed 
secondary  symptoms  without  ever  having  had  a  chancre. 

Theoretically  it  would  be  difficult  to  conceive  of  a  more 
perfect  mechanism  for  the  transmission  of  the  disease.  For 
granted  that  treponemata  are  present  onl}^  occasionally,  and 
in  small  numbers  in  the  spermatic  fluid,  yet  a  considerable 
quantity  of  this  fluid  is  deposited  at  each  act  of  intercourse 
and  may  remain  in  contact  with  the  female  genitalia  for  a 
prolonged  period.  With  repeated  inoculations  of  this  char- 
acter one  would  suppose  that  sooner  or  later  infection  would 
be  sure  to  occur. 

2.  The  Viability  of  the  Treponema  Pallidum  or  its  Ability 
to  Lice  and  Retain  its  Infectiousness  Outside  the  Body. — The 
Treponema  pallidum  may  retain  its  life  and  infectious 
properties  for  long  periods  in  tissues  that  are  excised  from 
the  body  and  in  various  bodily  fluids  when  kept  in  the  labora- 
tory under  suitable  conditions  or  in  cultures.     This,  however, 


122     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

is  aside  from  our  present  purpose,  whicli  is  to  determine  how 
long  this  organism  is  capable  of  retaining  its  infectiousness 
when  depoeited  upon  various  objects  with  the  secretions  from 
a  syphilitic,  in  order  that  we  may  determine  the  degree  of 
danger  incurred  by  those  persons  who  later  handle  these 
objects. 

The  actual  experimental  evidence  on  this  point  is  very 
satisfactory.  Hertmanni"^  found  that  the  treponema  lost 
its  motility  as  soon  as  drying  occurred.  The  time  of  drying 
depends  on  physical  laws,  and  experience  showed  that  drops 
of  serum  of  the  size  used  dried  in  from  fifteen  to  forty-five 
minutes  while  large  drops  of  blood  required  from  one  to  one 
and  a  half  hours  for  complete  drying.  Thin  smears  of  infec- 
tious material  on  absorbent  fabrics  would,  of  course,  dry 
much  more  rapidly.  Hertmanni  undertook  experiments  to 
determine  whether  material  that  has  dried  upon  razors, 
combs,  eating  and  drinking  utensils,  closet-seats,  etc.,  is  still 
capable  of  conveying  infection.  The  material  used  was 
obtained  from  syphilitics  and  mixed  with  the  serum  from  the 
lesion,  and  a  control  preparation  was  always  examined  by 
the  dark  field  and  the  presence  of  active,  living  treponemata 
established.  This  material  was  dried  for  varying  lengths  of 
time  and  then  redissolved  in  physiological  salt  solution. 
Investigation  of  these  dried  smears  showed  that  all  motility 
was  lost  as  soon  as  drying  occurred,  and  that  there  was  no 
return  of  motility,  although  the  preparations  were  observed 
for  over  four  hours. 

Neisser^'^  also  determined  that  virus  from  syphilitics 
that  produced  syphilis  when  inoculated  into  monkeys 
absolutely  lost  its  power  to  transmit  the  infection  as  soon 
as  the  fluid  which  contained  the  treponemata  was  dried. 
Gastou  and  Comandon"  have  investigated  the  question  of 
how  long  living  treponemata  would  remain  on  drinking 
glasses.  Individuals  with  mucous  patches  or  chancres  of 
the  lip  containing  many  treponemata  were  selected  to  drink 
from  the  glasses.  The  glasses  were  then  cleaned  after  the 
method  used  in  public  houses,  i.  e.,  some  time  after  use 
the  glasses  were  rinsed  in  water.  It  developed  that  the 
saliva  or  the  slimy  secretion  in  which  the  treponemata  were 


THE  SOURCES  OF  INFECTION  123 

contained  by  its  adhesion  to  the  glass  retained  the  organisms 
under  almost  as  good  conditions  as  the  mucous  patches 
themselves  until  the  material  had  entirely  dried.  Living 
and  active  treponemata  were  recovered  from  these  glasses 
up  to  a  half-hour  after  they  were  deposited  on  the  glass. 
Scheuer-^  experimented  with  sponges  contaminated  with 
syphilitic  secretions  and  found  living  treponemata  after  one 
and  a  half  hours. 

We  may  therefore  regard  it  as  demonstrated  that  any 
material  that  has  dried  has  lost  its  power  to  transmit  the 
infection.  This  is  a  matter  of  the  greatest  practical  impor- 
tance, since  it  is  evident  that  most  infected  objects  will  only 
remain  infected  for  a  short  time  if  they  are  of  such  a  nature 
as  to  permit  of  the  drying  of  the  material  deposited  upon 
them. 

Neisser  also  determined  that  infectious  material  lost  its 
power  to  transmit  infection  after  being  exposed  to  unfavor- 
able temperatures  as  follows:  (1)  after  three  hours  at  a 
temperature  of  10°  C;  (2)  after  twenty  hours  in  an  ice- 
chest;  (3)  after  heating  to  48°  C.  for  half  an  hour.  Mucha 
and  Landsteiner-^  and  Eitner^"  obtained  similar  results  and 
found  that  treponemata  that  lived  several  days  at  room 
temperature  died  in  from  five  to  six  hours  at  20°  to  27°  C, 
and  only  lived  fifteen  minutes  at  45°  C.  Bronfenbrenner 
and  Noguchi'^i  found  that  Treponema  pallidum  suspended 
in  physiological  salt  solution  is  killed  by  the  temperature  of 
45°  C.  in  from  seven  to  ten  minutes,  and  that  they  are 
killed  by  solutions  of  mercuric  chloride,  tricresol,  phenol, 
etc.,  in  dilutions  from  twenty  to  one  hundred  times  higher 
than  are  required  to  kill  the  colon  bacillus. 

Zinsser  and  Hopkins,^^  however,  showed  that  the  Trepo- 
nema pallidum  may  live  eleven  and  a  half  hours  on  wet 
towels  exposed  to  room  temperature  and  daylight.  We  have 
therefore  an  organism  that  cannot  survive  drying,  extremes 
of  temperature  or  light,  and  is  also  easily  killed  by  disinfec- 
tant. It  seems  quite  certain  therefore  that  treponemata 
seldom  live  for  any  long  period  of  time  after  being  deposited 
upon  objects,  and  it  is  probably  owing  to  this  fact  that  cases 
of  innocent  syphilis  are  not  more  frequent  than  they  are. 


124     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

These  facts  are  in  accordance  with  clinical  experience,  which 
indicates  that  in  almost  all  cases  in  which  a  chancre  is  believed 
to  have  been  received  from  some  intermediate  object  the 
victim  has  handled  it  very  shortly  after  its  use  by  the  syphi- 
litic person  from  whom  the  infection  originated.  Under  other 
circumstances  in  which  sufficient  fluid  is  deposited  upon  the 
object  for  it  to  remain  wet  for  a  longer  period  the  danger 
of  the  transmission  of  syphilis  is  proportionately  increased; 
and  as  the  experiment  of  Gastou  and  Comandon  indicates, 
syphilis  may  be  transmitted  by  a  drinking  glass  at  least 
half  an  hour  after  its  use  by  a  syphilitic.  Probably  the 
conditions  in  this  experiment  were  exceptionally  favorable, 
and  the  washing  to  which  the  glasses  were  subjected  may  have 
been  sufficient  to  keep  them  moist  and  insufficient  to  remove 
the  slimy  secretion  from  around  the  edges.  But  we  must 
conclude  that  any  object  recently  soiled  or  still  moist  with 
infectious  secretions  from  a  syphilitic  must  be  regarded  as  a 
possible  source  of  infection. 

C.  The  Methods  Whereby  the  Treponema  Pallidum  Gains 
Access  to  the  Body. — Certain  other  characteristics  of  the 
Treponema  pallidum  are  worthy  of  consideration,  since  they 
bear  upon  the  methods  of  transmission  of  syphilis.  These 
embrace  (1)  the  penetrative  powers  of  the  treponema  or 
its  ability  to  penetrate  sound  skin  or  mucous  membrane, 
and  (2)  the  tendency  for  these  organisms  to  become  localized 
in  the  genital  organs. 

1.  Penetrative  Powers  of  the  Treponeina  Pallidum. — It  has 
been  very  generally  held  that  the  Treponema  pallidum  is 
unable  to  penetrate  unbroken  skin  or  mucous  membrane 
but  that  the  organism  must  gain  access  to  the  body  through 
fissures  or  abrasions.  Indeed,  this  belief  may  almost  be 
accorded  the  rank  of  a  dogma,  for  statements  to  this  effect 
may  be  found  in  almost  any  standard  text-book  or  article  on 
syphilis.*    While  it  cannot  be  denied  that  the  presence  of 

*  Though  as  great  an  authority  as  Hutchinson,''  on  page  16  of  his  book, 
states  that  abrasions  are  not  essential  nor  perhaps  even  frequent  in  syphiUtic 
infections,  and  that  there  is  nothing  improbable  in  the  suggestion  that  the 
virus  can  easily  penetrate  the  unbroken  but  soft,  moist,  and  very  delicate 
mucous  structures  of  the  parts  on  which  chancres  are  usually  seen. 


THE  SOURCES  OF  INFECTION  125 

such  fissures  or  abrasions  favors  tfie  entrance  of  the  virus, 
and  that  many  or  perhaps  a  majority  of  infections  are  so 
acquired,  it  is  difficult  to  understand  on  what  facts  the 
statement  that  the  treponema  cannot  penetrate  the  unbroken 
mucous  membrane  is  based.  In  the  first  place  it  is  a  negative 
statement  and  is  therefore  insusceptible  of  proof;  while, 
on  the  other  hand,  the  known  facts  in  regard  to  this  infection 
appear  to  me  to  contradict  this  statement. 

Consider  first  the  organism  itself.  It  may  be  briefly 
described  as  an  animated  corkscrew,  and  anyone  who  has 
seen  the  living  organism  in  the  dark  field  and  observed  its 
slender  pointed  ends,  its  rotary,  lateral  and  progressive 
motility,  will  agree  that  it  is  admirably  constructed  for 
penetrating  purposes.  It  has  been  found  that  boils  and  skin 
infections  may  be  produced  by  rubbing  cultures  of  virulent 
staphylococci  on  the  unbroken  skin.  If  this  is  true  of  a 
non-motile  coccus,  why  should  we  deny  the  ability  of  an 
organism  like  the  Treponema  pallidum  to  penetrate  the  skin? 

Next,  consider  the  locations  in  which  the  organism  is 
found  in  the  tissues.  It  is  found  practically  everywhere; 
but  to  cite  one  example,  it  is  known  that  it  is  present  in  the 
brain  tissue  in  paresis  (Noguchi).  These  organisms  could 
not  have  reached  their  final  resting  place  without  penetrating 
some  tissues,  even  allowing  for  their  original  distribution 
through  lymph  channels  and  bloodvessels.  I  have  already 
quoted  the  statements  of  Pasini  and  Hoffman  to  the  effect 
that  these  organisms  may  be  found  within  certain  cells. 
Now,  if  this  organism  can  penetrate  certain  cells,  as  it  must 
to  reach  the  locations  in  which  it  is  found,  why  should  we 
assume  that  it  cannot  penetrate  the  cells  of  the  mucous 
membrane,  which  are  certainly  not  very  tough  or  resistant? 

Finally,  let  us  consider  clinical  observations.  It  is  to  my 
mind  inconceivable  that  all  of  the  innumerable  chancres, 
located  in  all  parts  of  the  body,  are  predicated  upon  a  pre- 
existent  abrasion.  Granting,  for  the  sake  of  argument,  that 
this  is  true  of  all  chancres  on  the  exterior  of  the  body,  how 
are  we  to  account  for  the  interurethral  chancre  for  example? 
How  was  the  fissure  or  abrasion  acquired  in  the  mucous 
membrane  of  the  urethra?     It  seems  improbable  at  least, 


126     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

and  far  more  probable,  that  the  treponema  was  able  to 
penetrate  the  unbroken  membrane. 

The  kissing  party  reported  by  Shamberg^^  has  become 
classic,  and  it  may  be  remembered  that  eight  individuals 
acquired  chancres  of  the  lip  from  kissing  a  young  man  who 
also  had  a  chancre  of  the  lip.  Now,  is  it  reasonable  to 
suppose  that  all  of  these  girls  had  abrasions  or  fissures  on 
their  lips  and  that  the  organisms  were  carefully  deposited  on 
these  solutions  of  continuity?  The  percentage  of  infections 
here  was  so  high  (eight  were  infected  and  five  or  six  escaped) 
that  to  explain  them  in  this  manner  would  require  us  to 
believe  that  practically  no  one  has  an  unbroken  mucous 
membrane.  Shamberg  states  that  of  those  that  developed 
chancres,  4  had  no  knowledge  of  any  abrasion  on  the  lips 
prior  to  infection,  though  1  had  a  fissured  lip  and  1  was  in 
the  habit  of  biting  the  lips. 

Such  arguments  might  be  adduced  ad  infinitum  and  perhaps 
ad  nauseam,  but  may  be  omitted,  since  there  is  a  practical 
experiment  bearing  on  this  point.  Reasoner  has  performed 
experiments  at  the  Army  Medical  School  to  test  this  point. 
Eight  rabbits  were  inoculated  with  an  emulsion  of  trepone- 
mata  obtained  from  two  chancres  on  rabbits'  testicles.  This 
emulsion  was  placed  in  the  eyes,  mouth  and  nose;  .in  the 
vagina  in  two  instances;  on  the  penis  of  one  rabbit;  and  on 
the  skin  of  the  scrotum  and  groin  several  times.  Six  of  these 
experiments  were  negative,  but  the  two  rabbits  inoculated 
in  the  vagina  both  developed  syphilis.  In  1  case  there  was 
generalized  syphilis,  with  the  treponemata  demonstrated 
in  the  lesions  of  the  nose,  but  no  chancre;  and  in  the  other 
case  a  vaginal  ulcer  developed  one  month  and  eighteen  days 
after  the  inoculation,  in  which  many  organisms  were  demon- 
strated; and  this  rabbit  subsequently  developed  generalized 
syphilis,  lesions  being  found  in  many  organs,  including  the 
brain.  It  may,  of  course,  be  objected  that  in  these  two  cases 
an  abrasion  was  present.  It  is  impossible  to  meet  such  an 
argument,  and  no  experiment  can  be  devised  which  will 
positively  guarantee  an  absolutely  intact  integument.  It 
can  only  be  stated  that  in  this  experiment  the  utmost  care 
was  used  to  avoid  breaking  the  skin  or  mucous  membrane, 


THE  SOURCES  OF  INFECTION  127 

and  that  the  rabbits  were  kept  separately  and  all  due  care 
exercised  to  avoid  this  possibility.  Personally,  I  regard  this 
experiment  as  a  demonstration  of  my  long-standing  belief 
that  the  Treponema  pallidum  can  and  often  does  penetrate 
unbroken  mucous  membranes  and  possibly  unbroken  skin. 

2.  Genitotroinc  Tendency  of  the  TreiJonema  Pallidum. — 
There  are  several  circumstances  that  appear  to  indicate  that 
the  Treponema  pallidum  has  a  selective  affinity  for  the  genital 
organs.  Attempts  to  transmit  syphilis  to  rabbits  were  made 
in  many  instances  in  earlier  years,  but  were  generally  unsuc- 
cessful until  it  was  determined  that  the  sexual  organs  afforded 
the  best  place  for  the  multiplications  of  the  parasites.  Injec- 
tions of  syphilitic  material  into  the  scrotum  or  testicle  of 
rabbits  almost  never  fail  to  produce  a  syphilitic  lesion  in  the 
rabbit;  although,  as  stated,  failure  was  frequent  when  other 
locations  were  used  for  the  inoculation.  Further,  intravenous 
injections  of  syphilitic  blood  in  the  rabbit  may  result  first, 
and  sometimes  only,  in  lesions  of  the  scrotum  and  testicle 
(Nichols).  In  regard  to  monkeys,  Neisser"  states  that  the 
testicles  of  infected  animals  always  proved  to  be  infectious 
even  when  inoculations  with  the  spleen  and  bone  marrow 
failed,  and  that  "it  appeared  that  the  testicles  acted  par- 
ticularly well  and  long  as  a  depot  of  the  virus. "  Conversely, 
when  inoculating  monkeys  it  was  found  that  the  best  results 
were  obtained  when  the  virus  was  injected  into  the  testicle. 

In  man  the  chancre  is  located  on  the  genitalia  in  something 
over  90  per  cent,  of  the  cases,  but  we  must  exclude  this  fact 
from  consideration,  because  these  organs  are  the  parts  upon 
which  the  virus  is  commonly  deposited.  But  the  great 
liability  of  the  testicle  to  tertiary  lesions  is  well  known,  and 
treponemata  may  be  demonstrated  often  in  testicles  present- 
ing no  gross  lesions,  as  has  been  shown  by  Warthin.^^ 

Again,  in  the  case  of  dourine,  which  is  a  trypanosome  in- 
fection of  the  horse  transmitted  solely  by  sexual  intercourse, 
and  therefore  analogous  to  syphilis  in  man,  the  parasites  are 
said  to  multiply  best  in  the  testicle  in  experimental  inocula- 
tions of  the  rabbit,  either  direct  or  intravenous. 

All  of  these  observations  seem  to  indicate  that  the  Tre- 
ponema pallidum  has  an  actual  affinity  for  the  tissues  of  the 


128     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

genital  organs,  and  that  we  may  be  dealing  with  a  character- 
istic of  the  organism  that  has  been  acquired  in  the  course  of 
its  evolution  in  the  effort  to  perpetuate  itself.  If  true  the 
importance  of  this  circumstance  is  obvious.  The  reason  why 
such  an  overwhelming  number  of  chancres  are  located  on 
the  genital  organs  may  be  due  partly  to  this  fact  as  well  as 
to  the  reasons  usually  assigned,  and  the  special  affinity  of 
the  organism  for  the  testicle  becomes  important  because  of 
the  possibility  already  mentioned  that  syphilis  may  be  often 
transmitted  by  the  spermatic  fluid.  If  the  treponemata 
remain  in  a  virulent  condition  in  the  testicle,  even  though  no 
lesion  may  be  present,  and  may  at  any  time  be  emitted  in 
the  spermatic  fluid,  this  fact  must  be  taken  into  consideration 
when  permitting  syphilitics  to  marry.  And,  finally,  if  the 
parasite  favors  the  sexual  organs  as  a  habitat  the  sexual 
nature  of  the  disease  is  emphasized,  and  any  endeavor  to 
deny  the  essentially  venereal  nature  of  syphilis  and  to  regard 
it  simply  as  a  contagious  disease,  however  well  intentioned, 
will  necessarily  fail,  since  this  endeavor  is  founded  upon  what 
is  at  best  but  a  half-truth. 

3.  Syphilis  d'Emhlee. — This  is  a  term  used  to  define  cases 
of  generalized  syphilis  in  which  there  has  never  been  a  chancre 
or  primary  lesion.  For  many  years  it  has  been  maintained 
by  a  few  syphilologists  that  generalized  syphilis  can  develop 
without  the  previous  appearance  of  a  chancre  if  the  virus 
gains  access  directly  to  the  bloodvessels  or  lymphatics. 
Other  authors,  including  most  of  the  orthodox,  have  opposed 
this  conception,  and  state  that  a  chancre  must  always  appear 
at  the  port  of  entry  of  the  virus  and  that  generalized  syphilis 
without  a  chancre  is  not  possible.  The  question  is  of  con- 
siderable scientific  interest,  and  is  also  of  importance  in  any 
study  of  the  public  health  aspects  of  the  disease. 

It  is  a  common  experience  to  have  a  syphilitic  patient 
deny  all  history  of  a  chancre  or  sore  of  any  kind.  Physicians 
commonly  pay  no  attention  to  such  denials  on  the  ground 
that  all  venereal  patients  are  liars  who  prefer  to  tell  an 
untruth  when  the  truth  would  serve  better.  No  doubt  this 
is  often  the  case,  but  there  are  numerous  exceptions  to  this 
rule.    We  often  have,  for  example,  the  educated  and  intelli- 


THE  SOURCES  OF  INFECTION  129 

gent  men  who  say,  ''It  is  true  that  I  was  exposed  at  various 
times,  but  I  always  watched  myself  very  carefully,  and  I  am 
positive  that  I  have  never  had  any  sore  of  any  kind. "  This 
is  usually  not  a  falsehood.  The  patient  has  admitted  his 
breach  of  morals,  has  consulted  his  physician  in  good  faith 
and  there  is  no  reason  to  suppose  that  he  is  lying.  But  it  is 
well  known  that  the  chancre  is  often  atypical,  indeed,  that 
it  may  be  so  slight  as  to  entirely  escape  attention,  a  mere 
fissure  or  erosion.  Most  syphilologists  explain  such  cases  in 
this  way,  and  apparently  are  completely  satisfied  with 
this  explanation. 

But  there  is  still  another  class  of  patients  in  whom  this 
explanation  becomes  fraught  with  difficulties.  These  are  the 
cases  of  fresh  secondary  syphilis  in  which,  perhaps,  all 
knowledge  of  the  manner  by  which  the  infection  was  acquired 
is  denied  and  in  which  the  most  careful  and  painstaking 
physical  examination  fails  to  detect  any  sign  or  trace  of  a 
chancre.  Such  cases  are  often  called  cryptogenic  syphilis, 
and  while  naturally  somewhat  unusual,  are  not  at  all  rare. 
Most  of  these  cases  are  never  reported,  for  obvious  reasons, 
and  yet  there  are  a  good  many  in  the  literatme.  Almkvist*^* 
has  collected  23  such  cases;  Lane^^  has  recorded  6  more; 
and  there  are  undoubtedly  others.  The  2  cases  reported  by 
Mueller^^  are  particularly  interesting,  because  these  patients 
were  under  continuous  observation  from  the  time  of  exposure 
to  the  development  of  secondaries.  Briefly,  these  cases  are 
as  follows: 

Case  I. — On  November  6,  1896,  two  patients  applied  for 
treatment  who  had  had  intercourse  with  the  same  girl  four 
days  before,  but  had  had  no  other  intercourse  for  months. 

Patient  No.  1  had  gonorrhea,  and  after  ten  days  devel- 
oped a  small  ulcer  on  the  glans  that  became  indurated 
November  22.  The  inguinal  glands  enlarged  and  treatment 
with  mercury  was  started,  but  in  March,  1897,  the  patient 

*  Havas,  1894,  1  case;  Cardier,  1894,  2  cases;  Verchere,  1894,  3  cases; 
Mueller,  1898,  2  cases;  Marshall,  1899,  1  case;  Heuss,  1901,  1  case;  Reiss, 
1901,  1  case;  Cozanet,  1903,  1  case;  Blaschko,  1904,  1  case;  Jakowlew, 
1905,  2  cases;  Emery,  1906,  1  case;  Waelsch,  1909,  3  cases;  Magian,  1909, 
1  case;  Bottman,  1910,  1  case;  Covisa,  1910,  1  case;  Papee,  1911,  Incase. 
9 


130     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

developed  generalized  secondary  syphilis.  This  case  serves 
as  a  control. 

Patient  No.  2  had  no  gonorrhea  and  was  under  careful 
observation  all  the  time.  At  the  end  of  January  the  left 
inguinal  glands  became  painful,  but  the  lymph  vessels  on  the 
dorsum  of  the  penis  were  normal.  Eight  days  later  the  right 
inguinal  glands  enlarged  and  a  general  adenitis  developed. 
At  no  time  was  there  the  slightest  trace  of  a  primary  lesion. 
Early  in  February  generalized  syphilis  developed,  with  a 
macular  eruption,  condylomata  and  angina. 

Case  II. — ^An  intelligent  man,  aged  twenty-seven  years, 
who  had  had  gonorrhea  years  before,  but  otherwise  no 
venereal  disease.  Consultation  August  30,  1895.  Had 
intercourse  six  days  before,  the  only  one  in  the  last  half- 
year;  but  found  out  the  day  before  the  consultation  that  the 
girl  with  whom  he  had  had  relations  had  contracted  syphilis 
six  months  previously.  On  examination  nothing  could  be 
found — not  an  erosion,  not  a  herpes  nor  any  injury  to  the 
genitalia.  As  the  patient  was  engaged  he  reported  every 
two  days  in  order  that  a  chancre  could  be  excised  at  once 
should  it  appear.  Not  the  slightest  lesion  appeared,  although 
the  entire  body  was  investigated,  and  the  urethra  was  also 
examined  with  the  endoscope.  For  six  weeks  the  investiga- 
tion was  entirely  negative.  In  the  seventh  week,  right  and 
left  inguinal  adenitis;  eighth  week,  polyadenitis;  tenth  week, 
generalized  secondary  syphilis,  with  macular  eruption  and 
nocturnal  headaches.  He  was  then  placed  on  mercurial 
treatment,  but  had  a  relapse  March,  1896. 

Mueller  concludes  that  in  these  2  cases  all  errors  are 
excluded  and  that  they  prove  the  existence  of  syphilis  with- 
out a  primary  lesion.  Almkvist^^  does  not  accept  this  reason- 
ing, and  quotes  a  case  of  his  own,  of  a  similar  nature,  in  which 
no  chancre  could  be  found,  but  who  developed  a  slight 
secretion  from  the  urethra  in  which  treponemata  were  demon- 
strated, and  subsequently  a  small  erosion  was  found  in  the 
urethra  behind  the  fossa  navicularis.  Almkvist  concludes 
because  of  the  great  ease  with  which  such  a  small  erosion  may 
escape  observation,  that  it  is  not  possible  to  prove  that  a 
case  of  infection  without  a  demonstrable  primary  lesion  is  a 


THE  SOURCES  OF  INFECTION  131 

true  case  of  syphilis  d'emblee  and  not  a  case  of  concealed 
chancre. 

This  is  a  conclusion  with  which  most  syphilologists  have 
always  agreed.  However,  it  must  be  accepted  with  some 
caution,  for  the  reason  that  the  existence  of  undoubted  and 
undeniable  syphilis  d'emblee  has  been  demonstrated  in  a 
very  few  cases.  These  are  the  cases  in  which  a  physician  or 
his  assistant  were  accidentally  infected  by  a  needle  or  other 
instrument  while  operating  on  a  syphilitic.  There  are  at 
least  9  such  cases  in  the  literature  as  follows :  Hutchinson," 
2  cases;  Jullien,^^  2  cases;  Waelsch,^^  1  case;  Bettman,^"  1 
case;  Fordyce,^^  1  case;  Hazen,^^  i  case;  Nonne,^^  1  case. 

Some  of  these  cases  will  bear  repetition.  Jullien's  2  cases 
are  as  follows: 

A  surgeon  and  his  assistant  operated  on  a  woman,  aged 
thirty-two  years,  for  a  swelling  of  the  sternum,  and  after 
excision  and  scraping  they  sewed  up  the  wound.  The  needle, 
however,  was  blunt,  and  in  trying  to  force  it  through  the 
skin  the  surgeon  wounded  himself  deeply  in  his  right  index 
finger.  Subsequently  the  assistant  met  with  a  similar  mishap 
and  wounded  himself  on  the  same  finger.  In  both  instances 
the  puncture  healed  in  three  or  four  days.  On  dressing  the 
patient's  wound  eight  days  later  they  observed  phenomena 
in  the  wound,  which  suggested  the  possibility  of  syphilis; 
and  on  the  following  day  a  general  macular  eruption  appeared 
on  the  patient.  On  examining  her  genital  organs  a  healing 
chancre  was  discovered,  and  also  enlarged  inguinal  glands. 
Twenty-six  days  after  the  inoculation  the  surgeon  developed 
fever,  shivering  and  malaise,  and  remained  in  bed  one  day. 
At  the  same  time  the  site  of  the  needle  wound  became  sensi- 
tive and  a  slight  ulcer  appeared.  This  was  followed  on  the 
thirtieth  day  b}'^  a  macular  eruption  and  a  week  later  by 
mucous  patches  on  the  scrotum  and  tongue.  The  assistant 
showed  no  signs  of  infection  before  the  thirtieth  day;  when 
he  also  had  an  attack  of  fever,  and  though  no  changes 
appeared  at  the  site  of  inoculation,  a  macular  syphilide 
appeared  on  the  thirty-third  day. 

Waelsch's  case:  A  physician  operated  on  a  case  of  para- 
phimosis  in  an  individual   known   to  him  as  a  syphilitic. 


132     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

During  the  operation  he  broke  a  flask  of  soap  while  his  hands 
were  covered  with  blood  and  a  glass  splinter  made  a  deep 
wound  in  his  right  forefinger.  He  cleaned  and  dressed  the 
wound  and  continued  the  operation.  The  wound  healed  at 
once,  and  the  physician  watched  it  for  weeks,  but  no  indura- 
tion or  infiltration  appeared.  The  general  eruption  appeared 
about  two  and  a  half  months  after,  and  the  diagnosis  of 
syphilis  was  made  by  Waelsch,  who  remarks  that  this 
observation  had  almost  the  exactitude  of  an  experiment. 

Fordyce  says :  "  I  have  had  a  number  of  cases  in  which  by 
the  most  painstaking  search  it  was  not  possible  to  find  any 
evidence  of  an  initial  sore,  but  such  cases  were  shown  to  be 
definitely  syphilitic  by  secondary  symptoms  and  a  positive 
Wassermann.  I  have  under  observation  at  the  present  time  a 
male  nurse  who  pricked  himself  with  a  needle  used  for  taking 
blood  for  the  Wassermann,  directly  after  he  had  withdrawn 
the  blood  in  a  very  florid  case  of  syphilis.  There  was  abso- 
lutely no  lesion  at  the  site  of  the  puncture,  and  though  the 
patient  was  watched  for  secondaries,  nothing  appeared  for 
several  months,  when  a  few  papules  developed  between  his 
toes.    His  Wassermann  was  strongly  positive. 

To  these  cases  I  am  now  able  to  add  another  case  of  my 
own.  Dr.  X  took  an  examination  for  admission  to  the 
service,  in  the  course  of  which  a  slight  macular  eruption  was 
noticed  and  a  Wassermann  reaction  was  made  and  was 
strongly  positive.    Dr.  X  then  gave  the  following  history: 

Three  months  before  he  had  operated  on  a  patient  with  a 
very  sore  throat  and  greatly  enlarged  tonsils.  It  was  later 
found  that  this  patient  had  a  four-plus  Wassermann  and  was 
in  the  active  stage  of  secondary  syphilis.  Dr.  X  removed 
the  tonsils  with  a  snare,  and  during  the  operation  the  wire 
broke  and  cut  the  left  forefinger  almost  to  the  bone.  He 
continued  the  operation  and  then  cauterized  the  wound  with 
pure  carbolic.  The  wound  healed  readily  and  hardly  left  a 
scar,  and  although  watched  for  two  months  no  sore  of  any 
kind  appeared.  A  careful  physical  examination  of  Dr.  X 
was  made  and  showed  that  he  had  a  very  sore  throat  in  addi- 
tion to  the  macular  eruption  already  noticed.  He  did  not, 
however,  have  any  enlarged  glands,  although  the  epitrochlear 


THE  SOURCES  OF  INFECTION  133 

inguinal  and  axillary  regions  were  carefully  palpated,  nor 
was  there  any  trace  of  a  sore  or  scar  on  the  penis  or  any  other 
part  of  his  body.  He  stated  that  he  had  had  no  intercourse 
for  seven  years  and  had  never  had  a  sore  on  the  penis.  He 
also  offered  the  following  evidence  to  prove  that  he  was  free 
from  syphilis  before  the  date  of  the  operation  described  above. 
Several  weeks  before  the  operation  he  had  served  as  a  donor 
for  a  blood  transfusion,  and  at  that  time  a  routine  Wasser- 
mann  was  made  and  was  negative.  Dr.  X  was  sent  to  the 
hospital,  where  he  received  several  injections  of  salvarsan 
as  a  result  of  which  he  had  a  pronounced  Herxheimer  reac- 
tion, and  the  eruption  became  bright  red,  but  after  the 
fourth  injection  the  Wassermann  reaction  became  negative. 
This  indicates  that  previous  to  the  operation  in  which  he  cut 
his  finger  he  was  free  from  syphilis,  and  the  positive  reaction 
and  response  to  salvarsan  shows  that  three  months  after  the 
operation  he  was  in  the  active  secondary  stage  of  syphilis. 
No  other  port  of  entry  of  the  virus  could  be  found,  and  in  so 
recent  a  case  the  chancre  or  at  least  the  scar  should  be  found 
if  it  existed. 

It  has  been  shown  by  experiment  that  if  a  rabbit  be  given 
an  injection  of  syphilitic  virus  intravenously  it  will  usually 
develop  generalized  syphilis  without  the  appearance  of  a 
chancre  at  the  site  of  inoculation.  This  fact  and  the  above 
clinical  cases  demonstrate  conclusively  that  generalized 
syphilis  may  occur  without  a  primary  lesion. 

Indeed,  it  is  difficult  to  understand  why  syphilologists 
have  objected  so  strenuously  to  acknowledging  this  pos- 
sibility. It  has  been  generally  admitted  that  syphilis  does 
not  always  run  a  classical  course.  The  secondaries  are 
often  omitted  in  mild  cases  or  in  malignant  syphilis  in  which 
tertiary  lesions  may  follow  shortly  after  the  primary  infection. 
The  tertiary  lesions  are  often  omitted  entirely,  and  it  is  not 
at  all  uncommon  in  cases  of  tabes  dorsalis  to  find  that  both 
secondary  and  tertiary  symptoms  have  been  absent,  although 
no  treatment  was  received.  It  is  generally  recognized  that 
there  is  no  disease  in  which  any  particular  symptom  or  lesion 
must  be  invariably  present  to  establish  a  diagnosis.  Why 
should  the  chancre  be  the  only  sacred  symptom  without 


134     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

which  there  can  be  no  syphiHs?  It  has  already  been  noted 
that  the  chancre  may  be  small  and  trifling,  and  it  has  been 
shown  in  some  cases  that  small  erosions  or  perhaps  only  a 
herpes  is  all  that  can  be  demonstrated  as  the  lesion  caused 
by  the  entrance  of  the  virus.  Whoever  goes  so  far  as  to 
accept  such  trifling  lesions  as  the  initial  lesion  of  syphilis 
must  logically  admit  that  the  lesion  may  be  absent  altogether 
and  accept  the  possibility  of  syphilis  d'emblee.  Idiopathic 
tetanus  and  cryptogenic  septicemias  are  well  known  in 
which,  even  at  autopsy,  no  portal  of  infection  can  be  recog- 
nized. Why  should  syphilis  be  the  only  disease  in  which 
exception  to  the  general  rule  cannot  occur? 

The  subject  has  been  emphasized  at  this  length  because 
of  its  importance  in  the  public  health  aspects  of  the  disease. 
If  syphilis  d'emblee  is  a  rare  condition  it  is  of  no  importance, 
but  it  is  believed  that,  on  the  contrary,  it  is  rather  common. 
The  fact  that  only  a  few  cases  can  be  found  in  the  literature 
does  not  militate  against  this  belief  for  the  reason  that  few 
such  cases  can  be  proved  with  sufficient  scientific  accuracy 
to  warrant  recording  them.  But  many  of  the  so-called 
cases  of  cryptogenic  infection  were  probably  truly  cases  of 
syphilis  d'emblee,  and  indeed  were  so  considered  by  their 
sponsors,  although  perhaps  the  proof  offered  is  not  unassail- 
able. 

If  we  consider  the  fact  that  tears  of  the  mucous  membrane, 
fissures  and  erosions  are  rather  common  sequences  of  sexual 
intercourse,  and  that  in  their  production  the  small  blood- 
vessels and  lymphatics  are  necessarily  opened,  and  that  the 
treponema  is  an  actively  motile  organism  that  can  easily 
gain  access  to  these  opened  vessels,  it  seems  most  probable 
that  many  infections  are  acquired  in  this  manner. 

.  If  true  this  explains  the  fact  that  so  many  of  our  undeniably 
syphilitic  patients  deny  all  history  of  a  primary  lesion.  More 
important  it  points  to  the  fact  that  there  are  many  indi- 
viduals in  the  community  who  are  entirely  ignorant  of  the 
fact  that  j:hey  have  acquired  syphilis.  They  have  been 
exposed,  but  have  observed  themselves;  no  chancre  has 
appeared  and  they  consequently  think  that  they  have 
escaped  infection.     Perhaps  the  development  of  paresis  or 


THE  METHODS  OF  TRANSMISSION  135 

locomotor  ataxia  in  later  years  will  be  the  first  indication  of 
the  disease.  Some  such  explanation  must  be  forthcoming 
to  explain  the  great  prevalence  of  syphilis  as  shown  by 
Wassermann  surveys,  and  particularly  by  Warthin's  finding 
of  treponemata  in  a  third  of  his  adult  necropsies,  among 
individuals  who  strenuously  denied  the  possibility  of  syphilitic 
infection.  All  men  are  not  liars,  and  it  is  believed  that  many 
of  our  patients  are  telling  the  truth  when  they  deny  the 
existence  of  a  primary  lesion. 

THE  METHODS  OF  TRANSMISSION. 

Although  the  various  methods  whereby  syphilis  is  trans- 
mitted are  extraordinarily  multiplex  in  detail,  and  involve 
to  a  greater  or  less  degree  almost  every  relation  of  family 
and  social  life,  yet  fortunately  these  multifarious  methods 
may  be  resolved  into  a  simple  classification;  thus  clarifying 
greatly  their  consideration  from  a  public  health  stand-point. 
Thus,  syphilis  may  be  divided  into  two  main  categories: 
syphilis  of  the  innocent,  or  syphilis  insontium;  and  syphilis 
resulting  from  illicit  intercourse,  or  syphilis  pravorum. 
Syphilis  insontium  is  usually  further  subdivided,  in  accord- 
ance with  its  method  of  transmission.  For  our  present 
purpose  the  following  classification  will  be  used: 

A.  Syphilis  insontium,  or  syphilis  of  the  innocent: 

1.  Marital  syphilis,  or  syphilis  e  coitu  legitima. 

2.  Hereditary  syphilis. 

3.  Syphilis  sine  coitu,  manifested  by  extragenital 

chancres. 

B.  Syphilis  pravorum: 

1.  Adulterous  relations. 

2.  Clandestine  prostitution. 

3.  Open  prostitution. 

1.  Marital  Syphilis. — This  includes  all  syphilis  transmitted 
from  husband  to  wife,  or  vice  versa,  whether  through  coitus, 
kissing  or  other  methods.  The  subject  is  of  great  interest 
and  importance  because  marital  syphilis  is  so  frequent,  and 
because  the  individual  so  infected  is  invariably  an  innocent 
victim  of  the  disease,  and  usually  remains  ignorant  of  the 


136     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

infection,  and  therefore  receives  either  no  treatment  or 
insufficient  treatment. 

Syphilis  may  be  acquired  by  either  husband  or  wife  before 
or  after  marriage.  When  acquired  after  marriage  the  second 
party  is  almost  invariably  infected,  while  in  the  case  of 
syphilis  contracted  before  marriage,  although  the  prob- 
ability that  the  infection  will  be  transmitted  is  great,  the 
innocent  party  frequently  escapes. 

Transmission  from  Wife  to  Husband. — ^This  is  compara- 
tively rare.  The  great  majority  of  women  have  no  sexual 
relations  before  marriage,  and  after  marriage  are  faithful 
to  their  husbands.  While  there  are  numerous  exceptions  to 
this  general  rule,  and  syphilis  is  undoubtedly  transmitted 
from  wife  to  husband  on  occasion,  it  is  impossible  to  obtain 
any  figures  on  the  frequency  with  which  this  occurs,  owing 
to  the  great  difficulty  in  obtaining  the  exact  facts  in  each 
case.  Married  men  who  contract  syphilis  occasionally  claim 
to  have  had  no  extramarital  relations;  but  such  statements 
must  be  regarded  with  suspicion  in  the  absence  of  definite 
proof,  which  is  almost  never  forthcoming.  Transmission 
from  wife  to  husband  is  sufficiently  rare  to  render  its  dis- 
cussion unprofitable  from  a  public  health  point  of  view,  and 
in  any  case  the  methods  of  transmission  are  similar  to  those 
by  which  the  disease  is  transmitted  from  husband  to  wife. 

Transmission  from  Husband  to  Wife.- — Here  the  facts  are 
reversed.  Syphilis  is  exceedingly  rare  among  single  women 
of  the  better  classes,  and  more  or  less  uncommon  among  any 
single  women,  except  clandestine  and  regular  prostitutes. 
It  is,  on  the  other  hand,  fairly  common  among  married  women 
who  have  almost  always  been  infected  by  their  husbands. 
Approximate  figures  as  to  the  frequency  of  this  form  of 
marital  syphilis  are  obtainable.  Fournier**  states  that  the 
facts  in  his  clinic  have  shown  that  of  100  syphilitic  women, 
80  per  cent,  are  of  irregular  life  and  20  per  cent,  are  respect- 
able married  women.  In  other  words,  one  syphilitic  woman 
out  of  five  is  infected  by  her  husband  and  the  other  four 
are  all  immoral.  Among  the  married  women  in  Fom^nier's 
private  practice  in  75  per  cent,  of  the  cases  the  disease  was 
unmistakably  traced  to  the  husband.     Bulkley  states*^  that 


THE  METHODS  OF  TRANSMISSION  137 

in  his  own  private  practice  fully  50  per  cent,  of  the  females 
with  syphilis  acquired  it  in  a  perfectly  innocent  manner, 
whUe  among  the  married  women  the  percentage  would  be 
85  or  more.  Fournier^^  remarks  that  "  the  contagion  in  effect 
is  rendered  so  easy  by  the  intimate  and  incessant  contact 
that  results  from  marriage  that  it  is  almost  fatal,  and  it  is 
rare  that  the  wife  is  not  infected.  As  M.  Dechambre  says, 
'Syphilis  is  divided  among  husband  and  wife  like  the  daily 
bread. ' "  Still  worse,  in  a  large  percentage  of  cases  the 
disease  is  transmitted  almost  inunediately  after  marriage. 
Thus,  Fournier^''  states  that  of  a  total  of  572  syphilitic  women 
no  less  than  81  contracted  syphilis  from  their  husbands 
during  the  first  days  of  their  marriage.  To  be  sure  this  was 
written  in  1880;  but  who  can  be  sure  that  with  the  prevailing 
ignorance  concerning  this  disease  conditions  are  much  better 
now? 

Methods  of  Transmission  of  Syphilis  from  Husband  to  Wife. 
— According  to  Fournier^^  out  of  312  s^Tphilitic  women  218 
were  infected  by  a  husband  who  acquired  his  syphilis  before 
marriage  and  94  were  infected  by  a  husband  who  became 
syphilitic  after  marriage. 

The  Delayed  Chancre. — This  method  of  transmission  is 
probably  comparative!}^  rare  in  this  country,  but  according 
to  French  authors  it  is  not  infrequent  in  France  and  some 
other  countries  where  young  men  celebrate  the  close  of  their 
bachelor  days  by  an  orgy  with  former  mistresses.  Since  the 
primary  lesion  of  syphilis  does  not  develop  for  some  time 
after  the  infection  is  received,  under  the  circumstances 
described  above,  it  is  not  unusual  for  the  chancre  to  appear 
some  days  or  weeks  after  marriage  and  for  the  wife  to  become 
infected  before  the  small  and  painless  lesion  is  noticed. 
Clinical  authorities  have  placed  the  incubation  period  of 
syphilis  at  fifteen  days  for  the  minimum  and  forty-two  days 
for  the  maximum ;  and  this  corresponds  closely  to  the  results 
obtained  in  experimental  inoculation  of  animals.  In  a  series 
of  100  rabbits  inoculated  with  syphilis  by  Nichols  and 
Reasoner  in  the  laboratory  of  the  Army  Medical  School  the 
average  incubation  period  has  been  thirty-eight  days  and  the 
longest  sixty  days.      From  this  it  is  evident  that  the  pos- 


138     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

sibility  of  transmission  of  syphilis  to  the  wife  by  a  chancre 
developing  after  marriage  is  ever  present  in  any  case  in  which 
illicit  intercourse  has  occurred  within  two  months  of  approach- 
ing marriage. 

Secondary  Lesions  that  Escape  Notice. — Mucous  patches 
are  particularly  prone  to  occur  in  the  mouth  even  after  the 
disease  has  lasted  several  years  and  has  been  well  treated  in 
accordance  with  past  standards.  If  the  wife  has  escaped  a 
genital  infection,  either  by  good  luck  or  good  management 
on  the  part  of  the  husband,  she  may,  and  not  infrequently 
does,  develop  a  chancre  of  the  lip  as  the  result  of  kissing 
at  some  time  when  one  of  these  highly  infectious  lesions 
has  developed  unnoticed  in  the  husband's  mouth.  Diday^^ 
observes  that  secondary  lesions  in  a  man  are  relatively 
infrequent  on  the  genital  organs  and  very  common  in  the 
mouth,  and  that  when  a  man  has  a  chancre  of  the  penis  he 
knows  it  is  infectious;  but,  on  the  other  hand,  he  is  frequently 
ignorant  not  only  of  the  danger  of  mucous  patches  in  the 
mouth  but  of  their  presence.  For  these  reasons  Diday 
thought  on  theoretical  grounds  marital  syphilis  in  women 
should  usually  originate  in  the  mouth.  He  points  out, 
however,  that  practice  does  not  bear  this  out  and  that  there 
are  ten  vulvar  chancres  to  one  chancre  of  the  lip.  Fournier^^ 
states  that  in  the  vast  majority  of  cases  syphilis  is  trans- 
mitted to  the  wife  as  a  result  of  secondary  lesions.  The 
disease  is  infinitely  more  dangerous  at  this  stage  because  of 
the  great  variety,  wide  dissemination  and  infectiousness  of 
the  lesions.  The  mildest  and  slightest  lesions  of  this  period 
are  the  most  dangerous  because  they  are  most  apt  to  escape 
the  attention  of  the  husband.  We  may  conclude  that  in  the 
majority  of  cases  syphilis  is  transmitted  to  the  wife  when 
the  husband  is  in  the  late  secondary  period  of  the  disease; 
and  having  been  well  treated,  thinks  he  is  healthy,  but 
really  suffers  from  some  small,  and  perhaps  almost  imper- 
ceptible lesion  of  the  genitals  or  mouth.  Fournier^^  has 
collected  statistics  on  this  point  that  *  are  well  worth 
quoting : 

Of  142  men  who  contracted  syphilis  prior  to  marriage  and 
infected  their  wives: 


THE  METHODS  OF  TRANSMISSION  139 

6  were  in  the  incubation  stage,  the  chancre  having  incom- 
pletely developed. 
1  had  a  chancre  less  than  six  weeks. 

4  had  a  chancre  less  than  a  year  previously. 

6  were  known  to  have  been  syphilitic  for  three  months. 

7  were  known  to  have  been  syphilitic  for  four  or  five 

months. 

5  were  known  to  have  been  syphilitic  for  six  months. 

4  were  known  to  have  been  syphilitic  for  eight  months. 

4  were  known  to  have  been  syphilitic  for  a  few  months: 

not  more  definite. 
18  were  known  to  have  been  syphilitic  for  one  year. 

1  was  known  to  have  been  syphilitic  for  thirteen  months. 
12  were  known  to  have  been  syphilitic  for  fifteen  to  eighteen 

months. 
16  were  known  to  have  been  syphilitic  for  two  years. 

5  were  known  to  have  been  syphilitic  for  two  and  a  half 

years. 
9  were  known  to  have  been  syphilitic  for  three  years. 
1  was  known  to  have  been  syphilitic  for  three  and  a  half 

years. 

8  were  known  to  have  been  syphilitic  for  four  years. 

1  was  known  to  have  been  syphilitic  for  four  and  a  half 

years. 

6  were  known  to  have  been  syphilitic  for  five  years. 

2  were  known  to  have  been  syphilitic  for  five  and  a  half 

years. 
5  were  known  to  have  been  syphilitic  for  six  years. 
5  were  known  to  have  been  syphilitic  for  seven  to  seven 

and  a  half  years. 
5  were  known  to  have  been  syphilitic  for  eight  years. 

1  was  known  to  have  been  syphilitic  for  nine  years. 

2  were  known  to  have  been  syphilitic  for  ten  years. 

1  was  known  to  have  been  syphilitic  for  eleven  years. 

2  were  known  to  have  been  syphilitic  for  twelve  years. 

2  were  known  to  have  been  syphilitic  for  thirteen  years. 
1  was  known  to  have  been  syphilitic  for  fifteen  years. 
1  was  known  to  have  been  syphilitic  for  seventeen  years. 
1  was  known  to  have  been  syphilitic  for  eighteen  years. 


140     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

Thirty-seven  had  had  syphiHs  less  than  one  year;  31  had 
had  syphihs  from  one  to  two  years;  thirty  had  had  syphiHs 
from  two  to  three  years,  so  that  98  had  had  syphihs  less  than 
three  years. 

Of  154  women  who  were  infected  by  their  husbands  the 
time  of  infection  was: 

First  months  after  marriage,  10  cases. 

Second  month,  26  cases. 

Third  month,  20  cases. 

Fourth  and  fifth  months,  7  cases. 

Sixth  month,  1  case. 

First  month  of  marriage,  without  greater  accuracy,  53  cases. 

Second  half  of  first  year,  13  cases. 

Second  year,  9  cases. 

Third  year,  3  cases. 

Fourth  year,  3  cases. 

Fifth  year,  2  cases. 

Sixth  year,  3  cases. 

Seventh  year,  2  cases. 

Eighth  year,  1  case. 

Ninth  year,  1  case. 

From  this  it  will  be  seen  that  130,  or  84  per  cent.,  of  these 
women  were  infected  during  the  first  year  of  married  life, 
although  a  few  infections  occurred  as  late  as  the  ninth  year 
after  marriage. 

Syphilis  Transmitted  to  the  Wife  by  Cojiception.— Concern- 
ing this  Fournier**^  writes : 

"A  pure  girl  is  married  to  a  syphilitic  and  soon  develops 
symptoms  of  secondary  syphilis.  Examination  shows  no 
trace  of  a  primary  lesion.  The  objection  may  be  raised  that 
a  chancre  in  a  woman  is  often  a  small  fugitive  lesion  which 
may  escape  detection.  But  there  is  no  bubo,  which  is  not 
only  the  faithful  companion  of  the  chancre,  but  according 
to  M.  Ricord  is  also  a  posthumous  witness,  since  it  survives 
the  chancre  for  a  long  time.  No  trace  of  a  scar;  no  aden- 
opathy; in  a  word,  syphilis  d'emblee  without  a  chancre. 
Examination  of  the  husband  fails  to  show  any  infectious 
lesions  whatever.  The  woman  has  become  syphilitic  at  the 
contact  of  her  syphilitic  husband,  who  has  not  the  least 


THE  METHODS  OF  TRANSMISSION  141 

external  symptom  capable  of  conveying  the  contagion. 
Facts  of  this  kind  are  common;  are  frequent.  What  then  is 
the  key  to  the  mystery?  It  is  that  the  wife  is  pregnant  and 
has  become  syphiHzed  by  conception.  In  such  a  situation 
pregnancy  is  always  present.  The  woman  who  appears  to 
have  received  syphilis  from  her  husband  has  in  reality 
received  syphilis  from  her  child,  who  in  turn  received  it  from 
the  father." 

Diday^^  also  insists  that  this  method  of  infection  is  common 
and  mentions  the  following  case: 

"A  young  girl,  aged  sixteen  years,  had  a  single  coitus  with  a 
young  man  who  had  had  syphilis  for  six  months,  but  who  had 
been  treated  regularly  and  who  had  shown  no  symptoms 
after  a  month  of  treatment.  The  morning  after  the  coitus 
the  man  was  examined,  and  no  lesion  could  be  discovered 
on  his  genital  organs  or  on  the  rest  of  his  body.  The  girl 
became  pregnant  and  in  three  months  developed  generalized 
secondary  syphilis,  but  without  a  chancre  or  inguinal  aden- 
opathy.  She  was  treated,  but  gave  birth  to  a  syphilitic  child. 

Diday  mentions  a  number  of  such  cases  among  married 
women,  and  states  that  in  1  case  the  infection  with  syphilis 
dated  eight  months  after  marriage;  one  eighteen  months; 
once  three  years;  twice  from  four  and  a  half  to  six  years,  after 
marriage;  and  remarks:  "During  all  these  years  infection 
did  not  occur  even  during  the  excesses  of  the  honeymoon. 
It  was  only  later  when  both  love  and  syphilis  had  lost  their 
first  ardor  that  infection  attacked  the  poor  woman,  spared 
until  then.  What  happened?  Almost  nothing,  only  the 
husband  became  a  father.  Transmission  in  this  manner  is 
therefore  certain." 

At  the  present  day  it  is  generally  believed  that  paternal 
transmission  to  the  fetus  direct  is  impossible,  but  this  con- 
clusion should  be  accepted  with  some  reservation  in  view  of 
the  above  well-authenticated  observations.  We  have  already 
seen  that  treponemata  have  been  demonstrated  in  the  seminal 
fluid  of  syphilitics.  It  seems  most  probable  that  in  cases 
such  as  those  quoted  by  Fournier  and  Diday  the  infection  was 
transmitted  by  means  of  the  spermatic  fluid  which  contained 
treponemata  at  the  time  of  the  intercourse  that  led  to  con- 


142     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

ception;  that  the  ovum  was  thereby  infected;  and  that  the 
mother  was  not  infected  directly,  but  only  secondarily  from 
the  fetus. 

However,  it  is  an  academic  question  whether  the  mother 
was  infected  directly  or  only  secondarily.  The  plain  fact  is 
that  numerous  innocent  marital  infections  have  been  trans- 
mitted by  means  of  infected  spermatic  fluid  by  husbands  who 
thought  they  were  healthy.  This  leads  directly  to  a  discussion 
of  the  standard  of  cure  of  syphilis,  and  the  conditions  under 
which  a  syphilitic  may  be  permitted  to  marry  and  become  a 
father.  This  subject  will  be  discussed  in  the  following 
chapter. 

Accidental  Extragenital  Infection  of  the  Wife. — This  differs 
in  no  respect  from  the  extragenital  chancres  accidentally 
received  in  other  social  relations,  except  that  because  of  the 
very  close  contact  between  members  of  the  same  household 
extragenital  infection  is  especially  apt  to  occur  between 
husband  and  wife. 

2,  Hereditary  Syphilis. — The  methods  of  transmission  may 
be  briefly  summarized  as  follows: 

(a)  The  husband  has  syphilis.  He  infects  his  wife;  and 
she  infects  the  embryo.  Experience  indicates  that  this  is 
the  usual  method  of  transmission,  and  that  the  wife  is  often 
infected  soon  after  marriage.  The  treponemata  circulating 
in  the  blood  stream  of  the  mother  during  the  secondary 
period  of  the  disease  apparently  penetrate  the  placenta  with 
ease,  and  enter  the  blood  stream  of  the  child.  The  child 
naturally  has  no  trace  of  a  chancre,  so  that  it  may  be  noticed 
that  we  have  here  another  indication  of  the  possibility  of 
syphilis  d'emblee. 

(b)  The  husband  has  syphilis  and  infects  the  ovum  at  the 
time  of  conception;  the  wife  later  becoming  infected. 

(c)  The  wife  alone  has  syphilis,  and  infects  the  child  in  the 
same  manner  as  in  (a).  It  is  fairly  obvious  that  in  any  case 
of  hereditary  syphilis  the  mother  is  certainly  infected,  and 
the  father  is  usually,  but  not  necessarily,  infected. 

The  Results  of  Hereditary  Syphilis. — The  results  following 
the  syphilization  of  the  embryo  may  also  be  summarized  as 
follows:     The  earlier  the  fetus  is  infected  the  more  rapidly 


THE  METHODS  OF  TRANSMISSION  143 

the  syphilis  advances,  so  that  it  may  lead  to  the  death  of  the 
fetus  within  six  weeks.  When  the  infection  is  received  later 
the  child  may  be  born  with  the  symptoms  of  the  disease,  and 
if  the  infection  occurs  shortly  before  birth,  the  child  may  be 
born  apparently  healthy,  and  even  the  Wasserniann  reaction 
may  be  negative,  since  there  may  not  have  been  sufficient 
time  to  permit  the  development  of  this  phenomenon.  These 
are  the  children  formerly  considered  immune.  Some  of  them 
may  show  symptoms  soon  after  birth,  and  some  in  later  years, 
and  possibly  some  never  show  symptoms  that  lead  to  a 
diagnosis. 
We  have  therefore  the  following  possibilities: 

1.  The  infection  causes  a  cessation  of  development  and 
abortion. 

2.  The  fetus  grows,  but  is  born  before  the  normal  expiration 
of  intra-uterine  life  (premature  births). 

3.  The  fetus  goes  to  term,  but  is  born  dead  (stillbirths).    • 

4.  The  child  is  born  at  term  living,  but  with  unmistakable 
signs  of  syphilis,  and  dies  shortly. 

5.  The  child  may  show  no  symptoms  of  syphilis  at  birth, 
but  a  few  weeks  later  typical  symptoms  develop.  It  may 
die  or,  as  the  result  of  treatment,  may  live. 

6.  The  child  shows  no  symptoms  of  syphilis  for  weeks, 
months  or  possibly  years;  the  disease  being  latent,  and 
becoming  manifest  in  some  cases  as  late  as  twenty-eight  years 
in  the  tertiary  form  (so-called  syphilis  hereditaria  tarda). 

It  is  possible  that  the  child  of  syphilitics  is  not  invariably 
infected.  Such  parents  may  apparently  have  a  healthy 
child  that  remains  so,  and  this  child  may  be  followed  by  one 
infected  with  syphilis.  No  rule  w^hatever  is  observed  in  such 
cases,  which  apparently  occur  when  the  parents  are  in  the 
later  stages  of  syphilis  and  are  capable  of  transmitting 
treponemata  only  at  times.  It  is  clear,  however,  that  the 
greatest  care  must  be  exercised  in  deciding  that  such 
apparently  healthy  children  are  in  reality  free  from  the 
disease.  Many  of  these  apparently  healthy  children  have  a 
positive  Wassermann  reaction,  and  even  a  negative  reaction 
will  not  exclude  the  existence  of  syphilis  with  absolute  accu- 
racy, in  spite  of  the  fact  that  the  Wassermann  reaction  is 


144     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

positive  in  a  very  high  percentage  of  cases  in  hereditary 
syphilis. 

Some  authorities  have  also  held  that  since  syphilitic  parents 
are  constitutionally  affected  by  the  disease  their  germ  cells 
may  also  become  affected  or  deteriorated,  so  that  the  embryo 
resulting  from  their  union,  though  not  actually  infected,  is 
subjected  to  this  unfavorable  influence.  As  a  result  the  child 
may  be  puny,  weak  aDd  show  various  abnormalities,  though 
not  actually  syphilitic.  The  claim  is  made  that  in  this  respect 
the  poison  of  syphilis  acts  like  alcohol  or  lead.  There  are 
many  observations  indicating  that  the  children  of  alcoholics 
are  inferior,^^  but  such  observations  must,  for  the  present,  be 
accepted  with  a  certain  amount  of  caution. 

The  Comparative  Frequency  of  the  Results  of  Hereditary 
Syphilis. — Information  as  to  the  comparative  frequency  of 
the  various  results  of  syphilization  of  the  embryo  enumerated 
above  has  been  obtained  by  observing  the  histories  of  all 
pregnancies  and  the  resulting  children  in  a  large  number 
of  families  in  which  one  or  both  parents  were  syphilitic. 
Fournier  (quoted  by  Haberman)  counted  161  pregnancies  in 
18  families,  of  which  137,  or  85  per  cent.,  died  before  or  at 
birth;  and  he  found  that  in  purely  maternal  syphilis  84  per 
cent,  of  the  offspring  were  affected,  while  in  paternal  syphilis 
only  37  per  cent,  were  infected.  Fournier*^  also  gives  the 
following  figures:  of  85  pregnancies  observed  in  syphilitic 
women  in  his  private  practice,  58  died  before  or  at  birth,  and 
there  were  27  live  births.  Of  167  pregnancies  observed  in 
syphilitic  women  in  hospital,  145  died  before  or  at  birth; 
and  in  22  cases  the  infant  survived.  Fournier  also  quotes 
the  records  of  other  physicians,   including  the  following: 

Dr.  Coffin  observed  28  pregnancies  in  syphilitic  women  in 
which  there  was  only  one  living  birth,  all  others  dying  at 
birth  or  before. 

Dr.  Pileur,  observing  the  pregnancies  of  syphilitic  women 
for  ten  years,  found  that  of  414  such  pregnancies,  154  were 
terminated  by  abortion  or  stillbirths,  while  of  the  260  children 
born  alive  at  term,  141  died  after  a  short  delay  (only  22  lived 
more  than  one  month),  making  a  total  of  295  deaths  in  414 
pregnancies,  or  approximately  71  per  cent. 


THE  METHODS  OF  TRANSMISSION  145 

M.  Durac  observed  43  pregnancies  in  syphilitic  women,  in 
which  36  resulted  in  the  death  of  the  infant,  a  mortality  of 
83.7  per  cent. 

Diday*''  records  212  observations  of  syphilitic  women,  the 
total  of  whose  pregnancies  resulted  in  225  deaths  by  abortion, 
premature  birth,  death  at  birth  or  shortly  after.  Forty-nine 
infants  survived.  He  pessimistically  remarks  that  when  both 
father  and  mother  are  syphilitic  the  infant  has  no  chance  at 
all  to  escape  infection.  On  the  other  hand,  if  only  the  father  is 
syphilitic  the  chances  are  much  better,  as  he  may  succeed 
in  avoiding  infecting  his  wife. 

According  to  Haberman*^  a  study  of  Nonne's  cases  showed 
the  following:  90  syphilitic  families  were  examined,  of  whom 
8  remained  sterile.  In  the  remaining  82  families,  350  preg- 
nancies occurred;  91,  or  26  per  cent.,  ended  in  abortion; 
10,  or  2.9  per  cent.,  in  stillbirths;  65,  or  18.8  per  cent.,  died 
young;  183,  or  52.3  per  cent.,  remained  alive.  Of  the  latter 
only  119  were  examined;  36  were  found  normal  and  83  were 
infected.  Expressed  in  other  words,  47.7  per  cent,  of  the  off- 
spring of  syphilitic  parents  died  before  term;  only  52.3  per 
cent,  remained  alive,  and  of  these  35.8  per  cent,  were  syphil- 
itic. If  one  parent  was  diseased  there  was  a  child  mortality 
of  only  37  per  cent.,  while  if  both  were  diseased  between  47 
and  53  per  cent.  died.  Hochsinger  (quoted  by  Haberman) 
speaks  of  67  families  in  which  there  were  266  pregnancies, 
of  which  only  142  came  to  term  and  76  more  died  within  the 
first  few  days.  This  makes  a  total  of  218  deaths,  or  more 
than  81  per  cent.,  in  this  series. 

It  is  apparent  that  mortality  will  depend  upon  the  treat- 
ment received.  Fournier^"  gives  the  percentages  of  hereditary 
syphilis  as  influenced  by  treatment  as  follows: 

Inheritance. 

Father  and 
Treatment.  Father.  mother. 

None 59  82 

Short 36  85 

Medium 21  30 

In  the  light  of  our  present  knowledge  such  figures  are 
inaccurate.     The  figures  given  for  paternal  infection  are 
10 


146     INFECTION  AND  TRANSMISSION  OF  SYPHILIS 

very  high,  and  we  must  assume  that  the  mothers  were  also 
infected  in  these  cases,  although  perhaps  they  showed  no 
clinical  manifestations  of  the  disease.  The  Wassermann 
reaction  was  not  available  at  this  time.  However,  these 
figures  do  throw  considerable  light  upon  the  influence  of 
treatment  on  the  transmission  of  hereditary  syphilis,  and  that 
is  all  they  are  used  for  in  this  connection.  Raven^^  also 
points  out  that  the  prognosis  for  the  child  is  much  graver 
when  the  mother  is  diseased  than  when  the  father  alone  is 
syphilitic.  Fifty-two  syphilitic  Inen  occasioned  154  preg- 
nancies, of  which  one-half  lived.  In  20  cases  of  maternal 
syphilis  there  were  74  pregnancies  of  which  only  a  fifth  came 
to  term. 

Veeder^^  reports  331  pregnancies  in  100  syphilitic  families; 
131,  or  40  per  cent.,  died  before  term;  51,  or  15  per  cent., 
died  after  birth,  making  a  total  mortality  of  55  per  cent.; 
116,  or  35  per  cent.,  are  living  but  syphilitic;  and  33,  or  10 
per  cent.,  are  living  and  free  of  syphilis.  So  that  we  may 
say  that  in.  this  series  only  10  per  cent,  escaped  infection. 
As  this  is  a  recent  series  the  patients  presumably  received 
about  the  average  amount  of  treatment,  and  the  cases  were 
studied  in  accordance  with  modern  methods,  including  the 
use  of  the  Wassermann  reaction,  we  may  conclude  that  this 
series  typifies  the  results  of  syphilitic  infection  upon  the 
children  at  the  present  day. 

Enough  has  been  said  to  indicate  the  terrible  results  of 
syphilis  upon  the  unborn  children  and  to  indicate  the  neces- 
sity of  considering  the  prevention  of  this  great  infant 
mortality.  This  can  only  be  done  by  imposing  the  proper 
restrictions  on  syphilitics  before  marriage. 

Colles  and  Prof  eta's  So-called  Laws.- — In  1837  Colles  stated 
that  apparently  normal  women  bearing  syphilitic  children 
do  not  contract  syphilis  when  exposed  to  infection,  and 
Profeta's  law  states  that  a  child  showing  no  taint  but  born 
of  a  woman  suffering  from  syphilis  will  not  become  infected 
though  suckled  by  its  mother. 

It  has  long  been  thought  that  this  indicated  that  in  bearing 
a  syphilitic  child  the  mother  became  immune  to  the  disease. 
These  so-called  laws  were  inaccurate  generalizations  from 


THE  METHODS  OF  TRANSMISSION  147 

clinical  experience  alone,  and  the  deduction  that  immunity  to 
the  disease  was  produced  was  entirely  erroneous.  The  Was- 
sermann  reaction  in  these  cases  is  almost  invariably  positive. 
Many  studies  of  this  peculiar  phenomenon  have  been  pub- 
lished since  the  introduction  of  the  Wassermann  reaction, 
but  only  one  need  be  quoted  here.  Jeans^*  tested  the  blood  of 
85  mothers  of  syphilitic  children.  Of  these  85  mothers, 
74,  or  87  per  cent.,  denied  all  knowledge  of  infection,  nor  was 
there  anything  in  the  history  that  would  indicate  infection 
except  a  history  of  frequent  abortions.  Seventy-three  of 
these  85  women  gave  a  positive  Wassermann  test,  and 
5  of  the  others  were  tested  after  at  least  ten  years  had 
elapsed  between  the  birth  of  the  last  syphilitic  child  and 
the  time  of  the  test.  There  has  been  a  remarkable  una- 
nimity in  the  results  obtained  in  all  such  studies,  so  that 
we  are  forced  to  conclude  that  such  women  do  not  develop 
any  immunity  to  the  disease,  and  that  they  do  not  become 
infected  when  exposed  for  the  very  simple  reason  that 
they  are  already  infected  and  suffer  from  syphilis  though 
usually  without  clinical  manifestations  other  than  a  positive 
Wassermann. 

3.  Syphilis  Sine  Coitu  (Extragenital  Chancres). — Extragenital 
chancres  are  not  necessarily  acquired  innocently  but  may  be 
the  result  of  improper  practices.  Chancres  of  the  mouth, 
tonsil  and  rectum  are  not  infrequent  following  such  per- 
versions. On  the  other  hand,  genital  syphilis  is  not  neces- 
sarily due  to  immorality,  since  it  frequently  result'^  from 
marital  relations,  and  has  occasionally  occurred  following 
the  rite  of  circumcision.  But  in  this  discussion,  extragenital 
infection  includes  any  infection  in  which  the  lesion  is  acquired 
accidentally  and  is  not  the  result  of  sexual  intercourse.  The 
vast  majority  of  the  chancres  so  acquired  are  extragenital. 
It  is  particularly  desirable  to  make  this  distinction  from  the 
public  health  stand-point,  as  the  measures  taken  to  prevent 
syphilis  resulting  from  immorality  and  syphilis  acquired 
accidentally  are  naturally  quite  different. 

The  knowledge  that  syphilis  could  be  contracted  extra- 
genitally  was  common  at  the  close  of  the  15th  century. 
In    1504    transmission    between    nurse   and    suckling    was 


148     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

established.  Surgical  instruments,  and  especially  cupping- 
glasses,  were  incriminated  by  Seitz  in  1509  and  Renner  in 
1554.  In  1870-1871  infection  through  vaccination  was 
described  (Scheuer).  Since  that  time  the  literature  of  extra- 
genital chancres  has  become  very  rich.  Bulkley,*^  in  1894, 
wrote  a  monograph  on  Syphilis  in  the  Innocent,  and  from 
his  rich  personal  experience  and  a  search  of  the  literature 
up  to  1892  collected  12,000  cases  of  extragenital  chancres. 
The  literature  from  1892-1896  has  been  well  covered  by 
Miinchheimer,  who  collected  1207  cases,  and  Fournier,^* 
who  added  1124  cases.  Scheuer-^  has  searched  the  literature 
from  1896-1909  and  has  collected  5679  cases  of  extragenital 
chancres  during  this  period.  The  combined  data  obtained  by 
all  of  these  authors,  comprising  20,000  cases  of  extragenital 
chancres,  was  analyzed  by  Scheuer  to  indicate  the  location  of 
the  chancre,  the  method  of  transmission,  etc.  From  this  very 
large  number  of  cases  the  actual  methods  by  which  syphilis 
is  transmitted  extragenitally  may  be  stated  with  great 
accuracy. 

Frequency  of  Extragenital  Infection. — It  is  impossible  to 
give  the  exact  proportion  between  extragenital  and  genital 
chancres,  based  on  the  literature,  because  the  number  of 
cases  acquired  sexually  is  not  known,  and  the  majority 
of  the  extragenital  chancres  are  never  reported.  Almost 
every  physician  has  seen  a  few  without  reporting  them. 
Incidentally,  I  may  say  that  I  have  seen  5:  1  in  the  inner 
canthus  of  the  eye  in  an  assistant  to  a  laryngologist,  who 
undoubtedly  received  the  infection  from  rubbing  his  eye  with 
a  finger  soiled  by  handling  instruments  that  had  just  been 
used  on  a  syphilitic  case;  1  was  on  the  abdomen,  and  the 
method  of  transmission  was  never  discovered  with  certainty 
but  probably  originated  as  the  result  of  scratching  with  an 
infected  finger;  and  3  were  on  the  lips.  I  have  known  of, 
but  not  personally  seen,  a  considerable  number  of  such  cases 
that  have  never  been  reported;  and  finally  it  frequently 
occurs  that  a  patient  with  syphilis  claims  that  the  infection 
was  acquired  innocently  by  a  chancre  on  the  lip.  Many  of 
these  patients  are  lying  "to  save  their  face,"  and  it  is  impos- 
sible to  say  what  percentage  of  them  are  telling  the  truth. 


THE  METHODS  OF  TRANSMISSION  149 

The  statistics  of  clinics  where  a  very  large  number  of  cases 
of  primary  syphilis  are  seen  form  the  best  basis  for  estimat- 
ing the  proportion  between  innocent  extragenital  and  genital 
chancres  resulting  from  intercourse.  Such  statistics  have 
been  compiled  by  Bulkley^^  (page  25)  from  a  nmnber  of 
European  clinics.  In  a  total  of  7123  cases  so  analyzed,  6770 
were  genital  and  perigenital,  and  only  353,  or  approximately 
5  per  cent,  of  the  entire  number,  were  extragenital.  But 
Bulkley  thinks  that  extragenital  chancres  are  really  much 
more  frequent  than  would  be  indicated  by  these  figures 
because  they  are  taken  from  venereal  clinics,  where  most  of 
the  patients  go  for  diseases  acquired  in  sexual  intercourse. 
The  cases  of  extragenital  infection  occurring  in  special  clinics, 
such  as  for  the  eye,  throat,  etc.,  would  not  enter  into  such 
statistics;  and  Bulkley  thinks  extragenital  infections  may 
form  10  per  cent,  of  the  whole.  We  may  therefore  conclude 
that  innocent  extragenital  infections  constitute  from  5  to  10 
per  cent,  of  the  total  infections  with  syphilis. 

All  authorities  and  statistics  agree  that  extragenital 
chancres  are  more  frequent  in  women  than  in  men.  Hahn 
(quoted  by  Scheuer)  and  Bulkley  give  figures  that  indicate 
that  women  are  so  infected  twice  as  often  as  men.  Possible 
explanations  of  this  fact  are  that  more  men  are  genitally 
infected  than  women  because  of  the  more  frequent  immoral 
relations  of  the  former.  And,  consequently,  more  women 
than  men  are  susceptible  to  an  extragenital  infection;  and 
that  women,  as  mothers,  nurses,  wet-nurses  and  midwives 
are  more  exposed  to  infection  than  men. 

It  is  apparent  from  these  statistics,  and  from  the  fact  that 
20,000  cases  of  extragenital  infection  have  been  recorded  in 
the  recent  literature  already  quoted,  that  such  accidental 
infection  is  by  no  means  uncommon  and  that  its  incidence  is 
quite  sufficient  to  justify  a  careful  study  of  the  methods 
whereby  the  disease  has  been  transmitted  in  these  cases  in 
order  that  proper  hygienic  precautions  may  be  taken  to  avoid 
such  infection.  But  the  fact  cannot  be  glossed  over  that  the 
vast  majority  of  all  syphilitic  infections  are  acquired  from 
sexual  intercourse. 


150     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

Methods  of  Transmission. — The  methods  by  which  syphilis 
has  been  accidentally  transmitted  are  so  multifarious  that 
it  is  impossible  to  discuss  them  systematically  without  using 
some  kind  of  a  classification.  The  following  general  classi- 
fication is  given  by  Bulkley: 

A    o     1  •!•  1      •       (  1-  Epidemica. 

A.  byphihs  pandemica    \  ^    -pi 

f  1.  Economica. 

B.  Syphilis  sporadica      ]  2.  Brephotrophica. 

[  3.  Technica. 

Bulkley  further  subdivides  each  heading  into  a  most 
elaborate  classification  that  includes  practically  all  possible 
methods  whereby  the  disease  may  be  transmitted  sine  coitu. 
Those  especially  interested  in  extragenital  chancres  should 
consult  this  classification  (pages  17  to  20).  For  the  present 
purpose,  however,  this  classification  is  unsuitable.  Some  of 
the  methods  detailed  are  so  rare  as  to  be  negligible  to  the 
sanitarian,  who  rather  wants  to  know  particularly  the  most 
frequent  methods  of  transmission,  and  it  may  be  pointed  out 
that  so  far  as  epidemic  and  endemic  syphilis  insontium  is 
concerned  these  epidemics  are  largely  maintained  by  innocent 
marital  intercourse;  and  that  in  so  far  as  these  epidemics 
are  due  to  extragenital  infection  the  methods  of  transmission 
differ  in  no  respect  from  those  obtaining  in  sporadic  syphilis. 

The  location  of  a  chancre  provides  an  excellent  clue  as  to 
the  method  of  transmission  in  a  given  case.  The  location  of  all 
the  extragenital  chancres  recorded  in  the  literature  has  been 
given  as  a  matter  of  course,  and  by  analyzing  these  cases  we 
are  able  to  reach  a  definite  conclusion  as  to  which  methods  of 
transmission  are  most  important.  This  is  essential  informa- 
tion for  the  sanitarian,  for  if  the  common  and  usual  methods 
of  transmission  of  extragenital  syphilis  can  be  avoided  no 
great  effort  need  be  expended  on  the  prevention  of  infection 
by  methods  of  transmission  that  are  rare  or  only  occasional. 
Scheuer^^  has  analyzed  14,590  cases  of  extragenital  chancres 
in  regard  to  their  location  as  follows: 


THE  METHODS  OF   TRANSMISSION  151 

Lips 3880 

Vaccination 2144 

Breast 1569 

Tonsils 1104 

Fingers  and  liands 897 

Mouth 824 

Circumcision 753 

Eyelids 632 

Nostrils  and  thi-oat 423 

Perigenital 278 

Tongue 273 

Chin 252 

Cheeks        .      .    ' 228 

Cupping 181 

Arms 176 

Nose,  external 172 

Trunk 168 

Lower  extremities 167 

Tattooing 109 

Gums 97 

.Forearm 79 

Forehead  and  temples 69 

Neck 63 

Ears  and  head 52 


Total 14,590 

These  figures  furnished  by  Scheuer  may  be  further  analyzed 
to  demonstrate  the  most  frequent  methods  of  transmission. 
The  278  perigenital  chancres,  including  176  anal  chancres, 
are  undoubtedly  almost  all  contracted  during  sexual  inter- 
course, and  need  not  be  considered  in  the  present  discussion. 
This  leaves  14,212  extragenital  chancres  to  be  analyzed. 
These  fall  naturally  into  the  following  groups  in  the  order  of 
their  importance: 

Table  I. 

GROUP   1. — BUCCAL  INFECTIONS. 

Location.                                                                                  Number.  Per  cent. 

Lips 3880  27.44 

TonsUs 1104  7.80 

Mouth      .      .      .      .• 824  5.82 

Tongue 273  1.93 

Gums 97  0.68 


Total 6178  43.70 


152     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

GROUP  2. — MINOR  OPERATIONS   BY  IGNORANT  PERSONS. 

Operation.                                                                           Number.  Per  cent. 

Vaccination 2144  15.16. 

Circumcision 753  5.32 

Cupping 181  1.28 

Tattooing 109  0.77 

Total 3187  22.54 


GROUP   3. — ^NURSING  SYPHILITIC  CHILDREN,  BREAST-DRAWING, 

ETC, 

Number.  Per  cent. 

Breast  and  nipples 1568  11 .  09 

GROUP  4.- — ^PHYSICIANS,  MIDWIVES,   NURSES,   ETC. 

Number.  Per  cent. 

Finger  and  hands 897  6.34      ' 

GROUP  5. — MISCELLANEOUS. 

Number.  Per  cent. 

Eyelids f32 

Nostrils  and  throat 423 

Chin 252 

Cheeks 228 

Nose 172 

Trunk 168 

Lower  extremities 167 

Forearm 79 

Forehead  and  temple 69 

Neck 63 

Ears  and  head 52 

Total 2305  16.30 

The  essential  facts  brought  out  by  this  classification  are 
that  of  all  extragenital  chancres,  43.7  per  cent,  are  buccal; 
66.24  per  cent,  belong  to  the  first  two  groups,  and  83.67  per 
cent,  belong  to  the  first  four  groups.  Each  of  these  four 
groups  corresponds  in  the  main  with  certain  definite  methods 
of  transmission.  It  should  therefore  be  possible  to  prevent 
the  vast  majority  of  extragenital  infections  by  the  adoption 
of  comparatively  simple  sanitary  measures. 

Group  1. — Buccal  Infections. — A  certain  percentage  of 
buccal  infections  are  acquired  as  the  result  of  sexual  per- 
versions.   The  vast  majority  of  such  chancres  are  acquired 


THE  METHODS  OF  TRANSMISSION  153 

from  kissing,  and  in  accordance  with  this  is  the  fact  that 
27.44  per  cent,  of  the  total  number  of  extragenital  chancres 
are  located  on  the  lips.  The  remaining  cases  are  caused  by 
introducing  in  the  mouth  some  object  that  has  been  used 
recently  by  a  syphilitic. 

Group  2. — Minor  Operations  Performed  by  Ignorant 
Persons. — It  will  be  seen  that  under  this  heading  by  far  the 
greater  number  of  infections  have  been  transmitted  by 
vaccination.  The  importance  of  vaccinal  syphilis  in  the  past 
is  indicated  by  the  following  table  from  Scheuer,  in  which 
Miinchheimer  combines  the  figures  given  by  Berliner  and 
Bulkley  up  to  the  end  of  1896: 


Country. 

United  States 

Great  Britain,  Ireland  and  Colonies 

Italy 

Austria-Hungary  .... 
France,  Belgium  and  Colonies 
Germany,  Switzerland,  and  Holland 

The  vast  majority  of  these  cases  occurred  in  the  days  when 
arm-to-arm  vaccination  was  practised.  Since  the  introduc- 
tion of  bovine  lymph,  vaccinal  syphilis  has  become  relatively 
unimportant,  as  will  be  seen  from  the  classification  of  the 
methods  of  transmission  given  later  for  the  cases  occurring 
after  1896.  It  is  important  to  note,  however,  that  vaccinal 
syphilis  may  still  occur  through  carelessness  when  vaccinating 
en  masse  by  using  the  same  needle  or  knife  on  all  persons. 

The  next  method  of  transmission  in  this  group  in  point 
of  frequency  is  circumcision.  Many  extragenital  infections 
(5.32  of  the  total)  have  been  transmitted  by  the  performance 
of  this  rite  by  ignorant  persons  who  have  sucked  the  wound. 
The  operator  may  become  infected  in  the  mouth  from  a 
syphilitic  child  and  may  then  spread  the  infection  to  many 
other  children;  or  the  operator  may  already  be  infected. 
Although  this  practice  of  sucking  the  wound  is  being  gradually 
supplanted  by  a  better  surgical  technic,  it  is  still  common  in 
certain  localities. 

Cupping,  which  was  formerly  responsible  for  many  infec- 


Number  of 

extragenital 

infections, 

total. 

Number 

through 

vaccination. 

Per  cent. 

1339 

887 

66.2 

590 

204 

34.6 

1003 

209 

20.8 

902 

121 

13.4 

2778 

370 

13.3 

d     1082 

59 

5.4 

154     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

tions,  and  for  some  epidemics  of  syphilis,  is  now  no  longer  of 
importance  because  cupping  is  seldom  practised,  except  in 
occasional  cases  in  hospitals  or  under  the  care  of  physicians. 
Tattooing  is  responsible  for  a  certain  percentage  of  infec- 
tions, and  though  relatively  unimportant,  should  be  men- 
tioned because  the  practice  of  tattooing  is  still  common,  and 
many  operators  use  their  own  saliva  in  mixing  the  pigment 
or  put  the  needles  in  their  mouths. 

Group  3. — Syphilis  of  the  Breast  and  Nipples.— This  is 
an  important  heading  since  it  comprises  11.09  per  cent,  of 
the  total  number  of  extragenital  chancres.  In  the  vast 
majority  of  such  cases  the  infection  has  been  transmitted 
to  wet-nurses  by  suckling  syphilitic  infants.  A  healthy  wet- 
nurse  is  almost  certain  to  be  infected  by  a  syphilitic  infant. 
Wet-nurses  are  not  so  common  in  this  country  as  in  Europe, 
where  a  large  proportion  of  these  cases  of  extragenital 
chancres  occurred.  A  certain  percentage  of  chancres  of  the 
breast  have  been  caused  by  emptying  the  breast  by  the  mouth 
instead  of  by  a  breast  pump.  Mid  wives  and  poor,  ignorant 
women  often  perform  this  service  in  some  localities;  and  a 
number  of  cases  of  syphilis  transmitted  in  this  way  are  on 
record. 

Group  4. — Infection  on  the  Fingers  and  Hands. — This 
group  comprises  6.34  per  cent,  of  the  total  extragenital 
chancres,  and  the  victims  are  almost  wholly  physicians, 
nurses,  midwives  and  other  persons  who  attend  the  sick. 
In  the  last  thirteen  years  of  this  series  168  cases  of  extra- 
genital syphilis  in  physicians  have  been  published,  so  that  it 
may  almost  be  called  an  occupational  disease  of  physicians. 
In  20  cases  the  victim  was  an  obstetrician  or  gynecologist. 
Examination  of  female  genitalia  is  often  practised  without 
inspection  under  the  bedclothes,  and  hangnails  and  slight 
abrasions  of  the  skin  of  the  fingers  are  most  common,  so 
that  the  opportunities  for  infection  in  this  way  are  legion. 
Surgeons  are  also  often  affected,  particularly  while  excising 
buboes.     Dentists  frequently  are  infected. 

Scheuer  has  also  tabulated  the  method  of  transmission  in 
1450  extragenital  chancres  occurring  from  January  1,  1896, 
to  January,  1909,  including  all  cases  in  which  the  method 


THE  METHODS  OF  TRANSMISSION  155 

of  transmission  was  known.     I  have  subdivided  this  table 
into  groups  as  follows: 

Table  II. 

GROUP   1. — BUCCAL  CONTACT. 

Number.  Per  cent. 

Kissing 192  13.24 

Instruments  used  in  certain  callings,  such  as 
glass-blowers,  musicians,  and  chemists  .      .       37 

Smokers'  articles 28 

Drinking  glasses 26 

Eating  utensils 22 

Toothpicks 5 

Artificial  feeding  of  children 10 

Total 320  22.07 

GROUP   2.— PATIENTS   INFECTED   BY  PHYSICIANS. 

Number,  Per  cent. 

Vaccination 272 

Infected  instruments        .......        46 

Total 318  21.93 

GROUP   3. — ^ACQUIRED   THROUGH   MEDICAL   ATTENTION   TO 

PATIENTS. 

Number.  Per  cent. 

Physicians 168 

Midwives 64 

Nurses 17 

Unlicensed  physicians 8 

Volunteer  nurses 6 

Total .     263  18.13 

GROUP   4.— ACQUIRED  THROUGH  CARE  OF  SYPHILITIC  CHILDREN. 

Number.  Per  cent. 

Nursing 169 

.  General  care  and  handling    ......        91 

Total 260  17.93 

GROUP   5. — TRANSMITTED  TO  OTHER  MEMBERS  OF  FAMILY  BY 
CLOSE  FAMILY  ASSOCIATION. 

Number.  Per  cent. 

Personal  contact 36 

Common  use  of  toilet  articles,  medicines,  etc.  32 

Handling  of  clothing,  wash,  etc 17 

Sleeping  with  a  syphilitic 11 

Play,  games,  etc. 5 

Total 101  6.96 


156     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

GROUP  6. — MINOR  OPERATIONS  PERFORMED  BY  NON-MEDICAL 

MEN. 

Number.  Per  cent. 

Barbers  and  shaving  utensils 44 

Tattooing 18 

Circumcision 7 

Total         69  4.75 

GROUP   7. — MISCELLANEOUS. 

Number.  Per  cent. 

Contact  with  finger 45 

Biting 41 

Insect  bites  (?) 1 

Total 87  6.00 

GROUP  8. — UNNATURAL  SEXUAL  T  RACTICES. 

Number.  Per  cent. 

Total 32  2.20 

Consideration  of  this  table  and  comparison  with  Table  I 
shows  that  immediate  or  mediate  buccal  contact  with 
syphilitics  is  the  most  frequent  method  of  extragenital  trans- 
mission. The  percentage  (22.07)  is  considerably  lower  than 
that  given  for  buccal  infection  in  Table  I  (43.7).  But  in 
Table  II  the  classification  is  by  method  of  transmission 
without  regard  to  location  of  the  chancre,  and  in  many  of 
the  cases  included  under  unnatural  sexual  practices,  family 
association  and  care  of  syphilitic  children  the  situation  of  the 
chancre  was  buccal.  The  great  danger  of  kissing  is  again 
emphasized  by  the  fact  that  192  infections,  or  13.24  per 
cent,  of  the  total,  were  definitely  known  to  be  transmitted 
in  this  way,  while  for  the  reasons  mentioned  above  this  is 
certain  to  be  an  underestimate. 

Group  2  of  Table  II  affords  the  greatest  and  most  painful 
surprise.  It  appears  from  this  that  no  less  than  21.92  per 
cent,  of  the  total  number  of  infections  considered  were 
transmitted  to  the  patients  by  physicians,  mostly  by  vaccina- 
tion. Vaccination  at  the  present  day  in  this  country  is  not 
responsible  for  so  many  infections  whatever  may  be  the 
case  in  certain  parts  of  Europe.     However,  the  number  of 


THE  METHODS  OF  TRANSMISSION  157 

patients  infected  b}'^  physicians,  according  to  Scheuer,  points 
a  moral  as  to  the  necessity  for  scrupulous  care  in  the  disin- 
fection of  instruments. 

Group  3  indicates  clearly  the  great  danger  to  which 
physicians  and  attendants  are  constantly  exposed,  and 
needs  no  further  comment.  Neither  does  the  great  danger 
of  handling  syphilitic  children  require  further  discussion, 
the  figures  show  that  17.93  per  cent,  of  the  total  infections 
were  transmitted  in  this  manner. 

Those  interested  in  the  exact  methods  of  transmission  in 
individual  cases  will  find  them  described  in  great  detail  by 
Bulkley  and  Scheuer.  For  the  present  pm-pose,  which  is  to 
provide  a  basis  for  the  consideration  of  sanitary  measures, 
the  classifications  presented  afford  more  information  than  a 
detailed  consideration  of  individual  cases. 

Syphilis  Fravorum. — We  have  already  seen  that  the  great 
majority  of  the  cases  of  marital  syphihs,  hereditary  sj^hilis 
and  even  extragenital  infections  are  derived  from  men 
already  infected  from  some  other  source.  By  determining 
this  source  of  infection  the  inquiry  is  pushed  to  its  logical 
conclusion. 

Such  statistics  are  difficult  to  obtain  in  this  country  where 
records  as  to  the  source  of  the  infection  are  seldom  kept,  but 
figiu-es  are  available  from  both  Paris  and  Berlin.  Fournier^^ 
found  that  of  867  men  infected  with  syphilis  and  observed 
in  hospital  practice  the  source  of  infection  was  as  follows: 

Number  of 

cases.  Per  cent. 

Open  prostitution 625  72 . 0 

Clandestine  prostitution 46  5.3 

Mistresses,  theater  women,  etc 52  6.0 

Working  girls 100  11.5 

Servant  girls 20  2.3 

Married  women 24  2.7 

Fournier  evidently  made  a  distinction  between  clandes- 
tine prostitutes  and  working  girls  who  were  immoral,  a  dis- 
tinction that  is  without  much  difference.  His  figures  show 
that  among  the  class  of  men  seeking  treatment  in  the 
hospitals  of  Paris,  72  per  cent,  of  all  syphilitic  infections 
were  derived  from  registered  prostitutes,  25.1  per  cent,  were 


158     INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

derived  from  clandestine  prostitutes  and  general  immorality 
and  only  2.7  per  cent,  of  these  infections  were  derived  from 
adulterous  relations. 

Blaschko^^  presents  a  similar  table  which  shows  80  per  cent, 
of  his  polyclinic  patients  with  syphilis  were  infected  by 
regular  prostitutes,  15  per  cent,  by  clandestine  and  irregular 
prostitutes  and  only  5  per  cent,  through  adulterous  relations. 

Further,  according  to  Blaschko,  Puche  found  that  of  510 
cases  of  syphilis  in  Paris,  374,  or  73  per  cent.,  were  infected 
by  inscribed  prostitutes,  and  that  Tschistjakow  found  that 
of  500  patients  who  knew  the  source  of  their  infection,  85.6 
per  cent,  were  infected  by  prostitutes  and  only  14.4  per  cent, 
by  women  who  were  not  prostitutes. 

Riggs^^  gives  the  following  table  indicating  the  source  of 
infection  among  sailors  who  contracted  venereal  disease  in 
Norfolk,  Va.,  or  vicinity: 


Number 

of 
disease. 

Chancroid. 

Gonorrhea. 

Syphilis. 

No. 

Per  cent. 

No. 

Per  cent. 

No. 

Per  cent. 

Inmates 
Street-walkers  . 
Clandestines 

184 

138 

43 

34 

24 
4 

17.9 

17.3 

9.3 

139 

102 

36 

75.5 
73.9 

83.7 

12 

12 

3 

6.5 
9.4 
6.9 

Snow"  states  that  the  records  of  a  venereal  clinic  for  men 
in  New  York  investigated  during  the  course  of  a  year  showed 
the  street  prostitute  to  have  been  the  source  of  infection  in 
36.6  per  cent.,  house  prostitutes  in  18.9  per  cent.,  domestics 
in  10  per  cent.,  friends  in  10  per  cent.,  working  women  in 
7.7  per  cent.,  wives  in  1.5  per  cent,  and  unknown,  14.7  per 
cent. 

There  is  good  reason  for  believing  that  among  the  better 
class  of  private  patients  the  percentage  of  infections  derived 
from  prostitutes  is  not  so  high.  Fournier  analyzed  387  cases 
of  gonorrhea  among  his  private  patients  and  found  that  only 
3.1  per  cent,  were  infected  by  regular  prostitutes,  while  90 
per  cent,  were  infected  by  clandestines  and  6.6  per  cent,  were 
infected  by  married  women.  We  may  assume  perhaps,  that 
the  figures  for  syphilis  would  not  be  very  different  among 


THE  METHODS  OF  TRANSMISSION  159 

this  same  class  of  men,  and  that  therefore  among  the  better 
classes  the  great  majority  of  infections  are  derived  from 
clandestines  rather  than  from  regular  prostitutes.  But  since 
these  better  classes  form  a  comparatively  small  part  of  the 
population,  and  since  syphilis  is  not  so  prevalent  among  this 
type  of  men  as  among  the  poorer  classes,  the  conviction  is 
forced  upon  us  that  the  great  bulk  of  syphilitic  infections 
among  men  are  derived  from  regular  prostitutes.  The  pro- 
portion of  infections  derived  from  adulterous  relations  is  so 
small  as  to  be  negligible,  so  that  we  may  conclude  that  more 
than  90  per  cent,  of  sexually  acqured  syphilitic  infections  in 
men  are  derived  from  prostitutes  either  open  or  clandestine. 
This  simply  means  that  any  sanitary  measures  taken  for 
the  prevention  of  syphilis  which  do  not  include  some  method 
for  treating  the  problem  of  prostitution  are  doomed  in 
advance  to  failure,  since  they  will  ignore  the  main  source  and 
root  of  the  disease. 

REFERENCES. 

1.  Ricord:  De  la  syphilis  et  de  la  contagion  des  accidents  secondaire, 
Paris,  1853. 

2.  Nouveau  traite  des  Maladies  v6n6riennes,  d'apres  les  documents  puises 
dans  la  clinique  de  M.  Ricord,  by  Dr.  Melchoir  Robert,  Paris.  J.  B. 
Bailli&re  et  fils,  1861,  pp.  vi  and  503  et  seq. 

3.  Buba:  Die  Contagiositatsdauer  der  Syphilis,  Inaug.  Dissertation, 
Leipzig,   1905. 

4.  Finger:     Wann  diirfen  Syphilitische  heirathen,  Heilkunde,  1897,  i,  351 . 

5.  Barthelemy:  Note  sur  la  prolongation  excessive  de  la  periode 
secondaire,  et  par  consequent  de  la  contagiosite  de  la  syphilis,  dans  ses  forms 
benignes,  Bull,  de  la  Soc.  Frangaise  de  Derm,  et  de  Syph.,  1896,  vii,  263. 

6.  Feiolard:  Duree  de  la  period  contagieuse  de  la  syphilis,  Ann.  de 
Derm,  et  de  Syph.,  1896,  3d  series,  vii,  1025-1048. 

7.  Newmann:  Dauer  der  Contagiositat  der  Syphilisprodukte ;  Con- 
tagiostat  der  tertiaren  Syphilis,  Wien.  med.  Presse,  1899,  xl,  i.- 

8.  Tarassewitch :  Contagiosite  Syphilitique  Tardive,  These  de  Paris, 
1897. 

9.  Kromayer:  Syphilitische  Uebertragung  nach  20  jahriger  Ehe  und  30 
jahriger  Infection,  Dermat.  Ztschr.,  1897,  iv,  708. 

10.  Tschistjakow:  Die  Condylomatose  Periode  der  Syphilis,  Inaug.  Dis- 
sertation, These  St.  Petersburg,  1894. 

11.  Landouzy:  Sur  le  contagion  syphilitique  au  dela  de  la  periode 
secondaire,  Comptes  rendus  du  I  Congrfes  de  derm,  et  syph.,  Paris,  1889, 
p.  713. 

12.  Fournier:  Echeances  du  Tertiarisme,  Comptes  rendus  du  I  Congr^s 
de  derm,  et  syph.,  Paris,  1889,  p.  717. 


160    INFECTION  AND   TRANSMISSION  OF  SYPHILIS 

13.  Lassar:  Ueber  die  Dauer  der  Contagiositat  der  Syphilis,-  Dermato- 
logische  Ztschr.,   1896,  iii,  533. 

14.  Doutrelepont  and  Grouven:  Ueber  den  Nachweis  von  Spirochete 
pallida  in  tertiar-syphllitischen  Produkten,  Deutsch.  med.  Wchnschr.,  1906, 
xxxii,  908. 

15.  Tomasezewski :  Ueber  den  Nachweis  der  Spirocheta  pallida  bei 
tertiarer  Syphilis,   Miinchen.  med.  Wchnschr.,   1906,  liii,   1301. 

16.  Finger  und  Landsteiner:  Untersuchungen  iiber  Syphilis  an  Affen, 
II  Mittheilung,  Archiv  f.  Dermat.  u.  Syph.,  1906,  Ixxxi,   147. 

17.  Neisser:  Pathologie  und  Therapie  der  Syphilis,  Berlin,  1911,  Arb. 
a.  d.  k.  Gsndhtsamte.,  1911,  xxxvii. 

18.  Hoffman:     Die  Etiologie  der  Syphilis,  Berlin,  1906,  p.  43. 

19.  Uhlenhuth  und  Mulzer:  Weitere  MittheUungen  ueber  die  Infectio- 
sitat  des  Blutes  und  anderer  Korperflussigkeiten  syphilitischer  Menschen  f. 
das  Kaninchen,  Berl.  klin.  Wchnschr.,  1913,  1,  769.  Also,  Ueber  die  Infek- 
tiositat  von  MUch  syphiHtischen  Frauen,  Deutsch.  med.  Wchnschr.,  1913, 
xxxix,  879. 

20.  Voss:  1st  die  Syphilis  durch  Milch  ilbertragbar?  St.  Petersburger 
Med.  Wchnschr.,  1876,  i,  No.  23,  1. 

21.  Dreyer  und  Toepfel:  Spirochete  pallida  in  Urin  bei  syphilitischer 
Nephritis,  Dermat.  Centralbl.,  1906,  ix,  No.  6,  172. 

22.  Pasini:  Infectiositat  der  physiologischen  Secrete  bei  hereditarer 
Syphilis,  Archiv  f.  Dermat.  u.  Syph.,  1908,  xcii,  236. 

23.  Hoffman:  Die  Aetiologie  der  Syphilis,  Dermat.  Ztschr.,  1909,  xvi, 
687. 

24.  Nichols,  H.  J.:  Observations  on  the  Pathology  of  Syphilis,  Jour. 
Am.  Med.  Assn.,  1914,  Ixiii,  466. 

25.  Warthin:  Persistence  of  Active  Lesions  and  Spirochetes  in  the 
Tissues  of  Clinically  Inactive  or  "Cured"  Syphilis,  Am.  Jour.  Med.  Sc, 
1916,  clii,  508. 

26.  Hartmanni :  Beitrage  zur  Lebensdauer  der  Spirocheta  Pallida,  Dermat. 
Ztschr.,   1909,  xvi,  633. 

27.  Gastou  et  Comandon:  Preuve  donne  par  I'ultra  microscope  de  la 
contagion  possible  de  la  Syphilis  par  les  verres  a  boire.  Bull,  de  la  Soc. 
Franc,  de  Dermat.  et  Syph.,  1908,  xix,  292. 

28.  Scheuer:  Die  Syphilis  der  Unschuldigen,  Berlin,  1910,  Urban  und 
Schwarzenberg. 

29.  Landsteiner  und  Mucha:  Zur  Technik  der  Spirochaetenunter- 
suchung,  Wien.  klin.  Wchnschr.,  1906,  xix,  1349. 

30.  Eitner:  Ueber  Beobachtungen  an  der  lebenden  Spirochaete  pallida, 
Miinchen.  med.  Wchnschr.,   1907,  liv,  770. 

31.  Bronfenbrenner  and  Noguchi:  On  the  Resistance  of  the  Various 
Spirochetes  in  Cultures  to  the  Action  of  Various  Chemical  and  Physical 
Agents,  Jour.  Pharmacol,  and  Exper.  Therap.,  1913,  iv,  333. 

32.  Zinsser  and  Hopkins:  The  Viability  of  the  Spirocheta  PaUida  in 
Diffuse  Light  at  Room  Temperature,  Jour.  Am.  Med.  Assn.,  1914,  Ixii,  1802. 

33.  Shamberg:  An  Epidemic  of  Chancres  of  the  Lip  from  Kissing,  Jour. 
Am.  Med.  Assn.,  1911,  Ivii,  783. 

34.  Almkvist:  Ueber  Syphilis  mit  verstecktem  Primaraffekt,  Dermat. 
Wchnschr.,  1913,  Ivi,  190. 

35.  Lane:     Syphilis  d'emblee,  Lancet,  June  15,  1912,  i,  1605. 

36.  Mueller:  Kryptogene  Syphilis  (Syphilis  d'emblee),  Dermat.  Ztsch., 
1898,  V,  213. 

37.  Hutchinson:     Syphilis,  Cassell  &  Co.,  1909,  p.  34. 


THE  METHODS  OF   TRANSMISSION  161 

38.  Jullien:  Kurze  Bemerkung  iiber  zwei  Falle  von  Syphilis  d'emblee, 
Monatsch.  f.  prakt.  Dermat.,  1902,  xxxiv,  531.  Also  described  at  length 
by  Lane. 35 

39.  Waelsch:  Ueber  Syphilis  d'emblee  und  die  Berufssyphilis  der 
Aerzte,  Miinchen.  med.  Wchnschr.,  1909,  Ivi,  8.50. 

40.  Bettman:  Zur  Frage  der  Syphilis  d'emblee,  Arch.  f.  Dermat.,  1910, 
c,  145. 

41.  Fordyce:  Modern  Diagnostic  Methods  in  Syphilis,  New  York  Med. 
Jour.,  1914,  c,  597. 

42.  Hazen:  A  Series  of  Twenty-five  Extragenital  Chancres,  Interstate 
Med.  Jour.,  1916,  xxiii,  661. 

43.  Nonne:  Der  Heutige  Standpunkt  der  Lues  Paralyse-Frage,  Archiv 
f.  Dermat.  u.  Syph.,  1914,  cxiv,  239. 

44.  Fournier:  La  syphilis  des  honnStes  femmes.  Bull,  de  1' Acad,  de  med., 
1906,   Ivi,    190. 

45.  Bulkley:  Syphilis  in  the  Innocent,  Bailey  and  Fairchild,  New  York, 
1894,  p.   197. 

46.  Fournier:     Syphilis  et  Marriage,  G.  Masson,  Paris,  1880. 

47.  Diday:  Le  Peril  Venerien  dans  les  Families,  Paris,  1881,  Asselin  et 
Cie. 

48.  Sullivan:  Study  of  the  Children  of  Female  Drunkards  in  the  Liver- 
pool Prisons,  Med.  Temp.  Rev.,  1900,  iii,  72. 

49.  Haberman:  Hereditary  Syphilis,  Jour.  Am.  Med.  Assn.,  1915,  Ixiv, 
1141. 

50.  Fournier:     Quoted  by  Finger,  Ref.  4,  Heilkunde,  1897,  i,  348. 

51.  Raven:  Serologische  und  Klinische  Untersuchungen  bei  Syphilitiker 
Familien,  Deutsch.  Ztschr.  f.  Nervenh.,  1914,  li,  342. 

52.  Veeder:     Hereditary  Syphilis,  Am.  Jour.  Med.  Sc,  1916,  clii,  522. 

53.  Jeans:     Familial  Syphilis,  Am.  Jour.  Dis.  Child.,  1916,  xi,  11. 

54.  Fournier:     Les  Chancres  Extragenitaux,  Paris,   1897. 

55.  Blaschko:  Syphilis  und  Prostitution,  S.  Karger,  Berlin,  1893,  pp. 
84-86. 

56.  Riggs:  The  Prevention  of  Venereal  Diseases  at  the  Naval  Training 
Station,  Norfolk,  Va.,  U.  S.  Naval  Bulletin,  1917,  xi,  1. 

57.  Snow,  William  F. :  Occupations  and  the  Venereal  Diseases,  Jour. 
Am.  Med.  Assn.,   1915,  Ixv,  2054. 


11 


CHAPTER   III. 

PERSONAL  PROPHYLAXIS. 

Having  discussed  the  wide  prevalence  of  syphilis,  and  the 
sources  and  methods  of  infection,  we  are  led  naturally  to 
consider  what  methods  may  be  employed  to  reduce  the  inci- 
dence of  the  disease.  These  methods  may  be  logically  divided 
into  those  that  may  be  taken  by  the  individual,  and  those 
that  may  be  taken  by  the  community.  We  propose  here  to 
discuss  those  methods  that  may  be  taken  by  the  individual. 

I.  METHODS     THAT    MAY    BE    TAKEN    BY    THE   INDI- 
VIDUAL TO  PREVENT  GENITAL  INFECTION. 

That  prophylactic  measures  taken  by  the  individual  con- 
stitute one  of  the  most  important  methods  for  the  reduction 
of  syphilis  can  hardly  be  doubted,  provided  these  methods 
are  efficacious.  Marschalko^  as  a  result  of  the  discussion  that 
took  place  at  the  Brussels  Conference  in  1901  concludes 
"That  the  present  system  of  reglementation  of  prostitution 
can  produce  little  result  in  the  reduction  of  syphilis  and  no 
results  whatever  in  the  reduction  of  gonorrhea  and  that  it  is 
therefore  time  to  place  the  prophylaxis  of  venereal  diseases 
upon  a  sound  basis,  educating  the  public  to  place  the  chief 
dependence  upon  personal  prophylaxis. " 

But  these  methods  of  personal  prophylaxis  constitute  one 
of  the  subjects  concerning  which  there  is  endless  debate, 
and  there  has  been  no  consensus  of  opinion  either  as  to  the 
efficacy  of  these  methods  or  as  to  their  morality.  The  writer 
will  endeavor  to  present  the  facts  available  that  bear  on  this 
question,  with  the  conclusions  that  he  deduces  from  these 
facts,  in  the  hope  that  those  who  differ  from  his  conclusions 
will  at  least  find  the  presentation  of  the  facts  of  interest  and 
value. 

The  methods  that  have  been  used  to  avoid  syphilitic  infec- 


METHODS  TO  PREVENT  GENITAL  INFECTION     103 

tion  may  be  classified  as  surgical,  mechanical,  and  chemical ; 
historically  they  have  been  evolved  in  this  order. 

The  Surgical  Method. — Circumcision.- — This  operation  is  so 
old  that  it  would  be  unprofitable  to  discuss  its  origin.  It  has 
become  a  religious  ceremony  among  certain  races,  among 
whom  it  has  been  practised  continuously  from  periods  of 
remote  antiquity  to  the  present  time.  We  do  not  know 
whether  the  operation  was  devised  as  a  protection  against 
venereal  diseases  or  for  some  other  reason,  but  at  the  present 
time  it  is  often  recommended  as  a  prophylactic  against  such 
diseases. 

A  'priori  reasoning  would  lead  us  to  expect  that  circum- 
cision should  diminish  susceptibility  to  syphilitic  infection, 
and  that  therefore  if  it  were  generally  practised,  the  present 
incidence  of  syphilis  would  be  diminished.  For  even  if  it  be 
granted  that  the  prepuce  is  not  more  liable  to  infection  than 
the  remainder  of  the  penis,  yet  the  prepuce  would  be  the 
portion  of  the  penis  to  receive  the  infection  in  a  percentage 
of  cases,  depending  upon  the  extent  of  the  skin  and  mucous 
membrane  on  the  prepuce  as  compared  with  the  extent  of 
skin  and  mucous  membrane  on  the  remainder  of  the  penis 
exposed  to  infection.  The  removal  of  the  prepuce  would 
therefore  diminish  the  area  exposed  to  infection  to  just  that 
extent. 

But  it  is  quite  possible  that  the  prepuce  is  more  liable  to 
infection  than  is  the  remainder  of  the  penis,  both  because  of 
its  delicate  mucous  membrane,  and  because  the  folds  into 
which  it  is  thrown  serve  to  retain  the  infectious  secretions. 
Jonathan  Hutchinson^  states  that  "the  most  frequent  posi- 
tion for  chancres  is  the  reverted  prepuce  just  behind  the 
corona."  Freeland^  has  compiled  the  following  figures  to 
show  the  relative  frequency  with  which  the  primary  lesion 
appears  on  the  prepuce,  as  compared  with  primary  lesions 
appearing  elsewhere  on  the  male  genitalia: 

Number  of        Number  on       Percentage  on 
initial  prepuce  and        prepuce  and 

lesions.  furrow.  furrow. 

Fournier 423  314  74.2 

Clerc 325  234  71.6 

Berkeley  Hill 150  111  74.0 

Total 898  659  73.3 


164  PERSONAL  PROPHYLAXIS 

From  these  figures  Moyer^  concludes  that  were  circum- 
cision generally  practised  the  incidence  of  syphilis  might  be 
reduced  from  50  to  70  per  cent. 

Moreover,  in  addition  to  this  liability  to  infection  of  the 
prepuce  itself,  this  covering  renders  the  glans  penis  more 
•  susceptible  to  infection.  The  mucous  membrane  of  the  glans 
is  always  kept  soft  and  delicate  and  thus  rendered  more  liable 
both  to  abrasions  or  to  actual  penetration  of  the  treponema 
through  intact  mucous  membrane.  Often  the  mucous  mem- 
brane of  the  glans  is  sodden  with  retained  secretions,  and 
should  these  secretions  decompose  or  become  irritating  the 
mucous  membrane  becomes  excoriated.  It  is  generally 
supposed  that  a  solution  of  continuity  is  necessary  for  the 
penetration  of  the  Treponema  pallidum.  Such  solutions  of 
continuity  are  therefore  already  provided  by  the  maceration 
caused  by  the  retained  secretions  of  a  redundant  prepuce, 
and  are  still  more  likely  to  occur  during  coitus  from  friction 
and  hair  cuts. 

While  the  writer  does  not  believe  that  such  solutions  of 
continuity  are  essential  for  the  penetration  of  the  Trepon- 
ema pallidum,  they  certainly  favor  infection.  Circumcision 
therefore  removes  a  useless  appendage  which  experience  has 
shown  to  be  peculiarly  liable  to  syphilitic  infection,  and  the 
hardening  of  the  mucous  membrane  of  the  glans  that  follows 
circumcision  most  certainly  renders  syphilitic  infection  much 
more  difficult  both  by  reducing  the  liability  to  abrasions 
either  before  or  during  coitus  and  by  affording  a  greater 
resistance  to  the  penetration  of  the  treponema.  On  theoretical 
grounds  alone  there  seems  to  be  sufficient  reason  to  recom- 
mend circumcision  as  a  proper  precaution  to  be  taken  especi- 
ally where  the  foreskin  is  unduly  long  or  tight.  It  can  be 
recommended  generally  for  the  undoubted  reason  that  it 
favors  cleanliness,  with  the  expectation  that  it  will  result 
in  a  considerable  degree  of  protection  against  sj^philis  and 
possibly  other  venereal  infections  if  the  individual  fails  to 
follow  the  recognized  standards  of  morality  in  regard  to 
continence  prior  to  marriage. 

Actual  statistics  as  to  the  prevalence  of  venereal  disease 
among  the  circumcised  as  compared  to  the  uncircumcised 


METHODS  TO  PREVENT  GENITAL  INFECTION     165 

are  very  difficult  to  obtain.  We  know  so  little  concerning  the 
real  incidence  of  syphilis  in  any  race  or  locality,  and  even 
when  Jew  and  gentile  live  together  in  the  same  community, 
and  if  it  were  possible  to  learn  the  incidence  of  syphilis  in  the 
two  races,  it  would  still  prove  little  because  we  would  have  no 
information  in  regard  to  the  relative  amount  of  exposure  to 
infection  in  the  two  races. 

Jonathan  Hutchinson  (quoted  by  Freeland),  however, 
gives  the  following  figures  concerning  330  cases  of  venereal 
disease  among  hospital  patients,  about  one-third  of  whom 
were  Jews: 

Total  venereal  Gonorrhea.  Syphilis. 

cases.  No.       Per  cent.  No.       Per  cent. 

Not  Jews        .      .     272  107         39.3  165         60.6 

Jews    ....       58  47         81.0  U         18.9 

This  table  indicates  not  only  that  the  incidence  of  syphilis 
is  far  less  frequent  among  the  Jews,  but  that  the  incidence  of 
gonorrhea  is  far  more  frequent,  thus  apparently  indicating 
that  the  comparative  immunity  to  syphilis  of  the  Jews  was 
not  due  to  any  excess  of  morality,  but  rather,  in  the  absence 
of  any  other  reason,  to  circumcision.  Hutchinson'^  elsewhere 
states  categorically  that  chancres  are  less  frequent  among 
Jews.  Freeland^  presents  no  figures,  but  states  that  "  During 
the  three  years  in  which  I  served  as  surgeon  to  the  Peninsular 
and  Oriental  Steam  Navigation  Company  I  never  remember 
to  have  seen  a  primary  syphilitic  chancre  among  the  Lascar 
crew,  who,  being  Mohammedans,  are  circumcised  to  a  man, 
while  among  the  Sedi  boys,  who,  for  the  most  part,  grow 
long  foreskins,  primary  sores  were  not  uncommon  nor  were 
the  European  crew  exempt.  Other  venereal  diseases  were 
prevalent  among  the  Lascars,  so  that  their  immunity  could 
not  be  ascribed  to  any  greater  morality  on  their  part. " 

Breitenstein<^  quotes  the  figures  compiled  yearly  by  the 
Dutch-Indian  Army,  which  includes  Europeans  and  Malays 
living  under  what  are  claimed  to  be  similar  circumstances. 
According  to  these  figures  the  Malays,  who  are  circumcised, 
have  from  two  to  five  times  less  syphilis  than  the  uncircum- 
cised  Europeans.  Thus  in  1895  the  rate  was  0.8  per  cent., 
for  the  natives  and  4.1  per  cent,  for  the  Europeans.     It  is 


166  PERSONAL  PROPHYLAXIS 

stated  that  the  opportunity  to  acquire  syphiHs  is  the  same 
for  both  races,  since  the  women  who  act  as  prostitutes  and  are 
the  source  of  syphihs  are  frequented  by  both  races.  Every 
soldier  may  have  a  housekeeper  and  Hve  with  her  in  barracks, 
and  both  races  may  marry.  Real  marriage  is  more  frequent 
among  native  soldiers  than  Europeans,  but  this  is  not  thought 
to  be  the  reason  for  the  natives'  comparative  freedom  from 
syphilis,  because  most  of  these  native  women  are  really 
common. 

These  statistics,  however,  fail  to  take  into  account  the 
probability  that  European  soldiers  will  consult  a  physician 
more  freely  than  will  natives,  and  therefore  the  real  amount 
of  syphilis  is  more  apt  to  be  known  among  Europeans  than 
among  natives. 

All  such  statistics  are  subject  to  so  many  fallacies  that  no 
good  purpose  would  be  served  by  quoting  them  at  greater 
length.  The  subject  of  circumcision  may  be  summarized 
briefly  as  follows :  On  theoretical  grounds  there  seems  to  be 
sufficient  reason  to  recommend  circumcision  as  a  preventive 
of  syphilitic  infection,  and  the  available  statistics  indicate 
that  when  circumcision  is  generally  practised  this  procedure 
does  actually  effect  a  reduction  in  the  incidence  of  syphilis. 
The  extent  of  this  reduction  cannot  be  ascertained  with 
certainty. 

Mechanical  Methods.^ — According  to  LePileur,^  Fallopius 
devoted  a  chapter  of  his  works  published  about  1555  to 
preventives  of  the  "French  disease."  He  recommended 
careful  washing  before  and  after  each  act  of  intercourse,  and 
also  the  use  of  a  mechanical  device  to  place  over  the  head 
of  the  penis.  This  latter  was  probably  useless,  although 
Fallopius  is  quoted  as  saying,  "Ego  feci  experimentum  in 
centum  et  mille  hominibus  et  Deum  testor  immortalem 
nullum  eorum  infectum."  This  is  apparently  the  first 
record  of  an  attempt  at  a  mechanical  device  for  protection. 

The  condom  was  invented  early  in  the  18th  or  late  in  the 
17th  century  in  England.  It  was  described  by  Turner  in 
1717,  who  attributed  its  invention  to  a  Dr.  Condon,  from 
whom  the  device  was  named.  LePileur,  who  has  made  a 
study  of  this  literature,  questions  the  existence  of  Dr.  Condon, 


METHODS   TO   PREVENT  GENITAL  INFECTION     167 

and  thinks  it  more  probable  that  the  name  is  derived  from  the 
Latin  verb  condere,  meaning  to  hide  or  to  protect.  The  first 
condoms  were  made  from  the  cecum  of  lambs,  which  were 
dried  and  rendered  phable  by  rubbing  between  the  hands  with 
oil  of  almonds.  Later  rubber  was  used,  and  as  the  art  of 
manufacturing  rubber  was  yet  undeveloped,  the  first  rubber 
condoms  were  very  unsatisfactory  and  broke  or  tore  during 
use.  During  this  period  the  condom  was  condemned  as 
unreliable  by  many  physicians.  In  recent  years  this  objec- 
tion has  been  practically  removed  by  the  use  of  a  better  grade 
of  rubber,  so  that  there  is  little  danger  that  the  condom  will 
break  during  use  if  it  is  not  too  old  and  has  been  tested 
previously. 

Most  authorities  agree  that  the  use  of  a  condom  is  an 
almost  certain  protection  against  syphilitic  infection,  being 
even  more  reliable  than  prophylactic  ointments.  Thus 
Butte^  in  reporting  2  cases  of  syphilitic  infection  following  the 
use  of  calomel  ointment,  said  that  "  if  they  had  used  a  vulgar 
condom  of  good  quality  the  result  would  have  been  difi^erent. " 
The  objections  to  the  use  of  such  a  mechanical  device  are 
practical  and  moral.  It  is  expensive,  can  be  purchased  only 
with  some  difficulty,  and  is  seldom  available  when  needed. 
It  is  open  to  objection  on  the  part  of  the  moralist,  on  the 
ground  that  it  is  improper  to  sell  or  distribute  an  article  which 
will  encourage  immorality  by  making  it  safe.  This  point  is 
discussed  later.  In  regard  to  the  protection  afforded  we  may 
conclude  that  the  condom  if  properly  tested  and  made  of 
good  rubber  will  afford  practically  complete  protection  to 
anyone  who  can  obtain  and  will  use  it,  and  it  may  there- 
fore be  recommended  to  those  individuals  who  persist  in 
immorality  in  spite  of  advice  to  the  contrary. 

Chemical  Methods  of  Prevention. — It  is  often  assumed  that 
mercurial  ointments  for  the  prevention  of  syphilis  came  into 
general  use  only  after  MetchnikofP's  observations  on  the 
prevention  of  syphilis  in  apes  by  the  use  of  calomel  ointment. 
This  is  not  the  case,  for  such  ointments  were  in  very  general 
use  long  before  the  time  of  Metchnikofi^.  According  to 
LePileur,''  Agato  in  1564  used  fumigations  of  cinnabar  as  a 
prophylactic,  and   Pierre  Desault,  of  Bordeaux  (1733),  de- 


168  PERSONAL  PROPHYLAXIS 

scribed  the  use  of  mercurial  ointment  as  a  prophylactic  after 
coitus.  Desault  reasoned  that  as  mercury  cured  syphilis 
and  killed  the  "small  worms"  that  had  penetrated  the  body 
it  ought  to  have  the  same  action  upon  these  organisms  which 
were  in  contact  with  some  part  of  the  body  but  had  not  yet 
entered. 

Warren,  an  English  physician,  in  1771  advised  every  man  of 
pleasure  to  carry  with  him  a  box  of  mercurial  ointment,  a 
bottle  of  welak  solution  of  caustic  potash  and  a  syringe.  One 
of  the  things  that  threw  discredit  upon  unguents  with  or 
without  the  use  of  mercury  was  the  vogue  obtained  by  liquid 
prophylactics  about  this  time.  Thus  about  1770  Guilbert  de 
Preval,  a  regent  of  the  faculty  of  the  University  of  Paris,  sold 
a  so-called  "Eau  Antivenerienne, "  which  was  a  fraud.  He 
claimed  that  it  contained  no  mercury.  It  was  proved  to 
contain  mercuric  chloride,  but  in  amount  too  small  to 
prevent  the  disease.  For  thus  selling  a  secret  remedy  and  the 
deception  as  to  its  composition,  Preval's  name  was  erased  from 
the  list  of  members  of  the  faculte  de  Paris.  Many  other 
solutions  were  used,  including  Labarraque's  solution,  per- 
chloride  of  iron  and  varioi:  s  mercurial  preparations  and  simple 
unguents. 

A  few  citations  from  various  writers  will  indicate  the  status 
of  proplylaxis  against  syphilis  just  prior  to  Metchnikoff's 
work.  Behrmann,^  in  1899,  states  that  nothing  is  known 
concerning  the  cause  of  syphilis,  but  that  as  we  can  prevent 
smallpox  without  knowing  the  cause  so  we  should  attempt  to 
prevent  syphilis.  Since  it  is  known  that  mercury  destroys  the 
syphilitic  virus  after  it  enters  the  blood,  and  since  we  apply 
calomel  and  mercurial  plasters  to  the  chancre,  he  suggests 
the  inunction  of  mercury  after  coitus  to  prevent  infection, 
and  gives  direction  for  its  use. 

Cohn,^"  in  the  same  year,  recommends  a  form  of  prophy- 
laxis often  advised  by  him  in  practice,  viz.,  heavily  smearing 
the  penis  with  a  mercurial  salve  ante  coitum  and  washing 
with  a  mercurial  soap  (sapo  ciner.,  Unna)  immediately  after 
coitus. 

Richter,^^  in  an  article  written  in  1901,  refers  to  Behrmann's 
method,  namely,  the  use  of  gray  ointment  (66  per  cent,  fat 


METHODS  TO  PREVENT  GENITAL  INFECTION     169 

and  33  per  cent,  mercury)  as  a  protection  against  both 
syphilis  and  gonorrhea.  He  quotes  one  observation  con- 
cerning a  young  man  who  served  as  an  experiment  for  four 
weeks,  during  which  time  he  had  about  forty  cohabitations 
with  eighteen  open  or  clandestine  prostitutes,  using  the  above 
prophylactic.  Two  of  the  prostitutes  were  known  to  be  in  the 
acute  stage  of  gonorrhea  and  one  in  the  acute  stage  of  syphilis, 
yet  he  escaped  all  infection. 

Loeb,i2  in  1901,  refers  to  47  cases  that  had  used  gray 
ointment  following  exposure.  Syphilitic  infection  followed 
twice  in  spite  of  all  inunctions.  Loeb  believed  the  method 
recommended  by  Dr.  Max  Joseph^^  namely,  to  first  anoint 
the  member  with  fat  and  subsequently  to  disinfect  with 
sublimate  solution,  is  best.  With  this  method  in  more  than 
100  cases  he  had  seen  only  1  case  in  which  syphilitic  infec- 
tion occurred  in  spite  of  these  precautions,  and  states  that 
this  proves  nothing  except  that  no  method  will  succeed 
invariably. 

Guiard,^^  writing  in  1901  and  referring  to  the  great  activity 
of  mercury  as  a  cure  for  syphilis  says :  "  It  is  certain  that  the 
quantity  which  circulates  in  the  body  and  suffices  for  a  cure 
is  infinitesimal.  In  prescribing  0.3  gm.  per  day,  an  average 
dose  for  a  man,  and  admitting  it  is  completely  absorbed,  there 
is  hardly  for  6  liters  of  blood  a  proportion  of  1  to  200,000.  If 
the  microbe  of  syphilis  cannot  withstand  this  it  is  irrational 
to  suppose  that  it  can  withstand  an  application  of  1  to  4000 
or  1  to  5000  when  it  has  not  yet  penetrated  and  when  the  drug 
is  therefore  applied  direct."  Such  quotations  might  be 
considerably  extended,  but  the  above  indicate  pretty  clearly 
the  status  of  syphilitic  prophylaxis  prior  to  Metchnikoff  s 
experiments.  It  will  be  remembered  that  at  this  time  the 
cause  of  syphilis  remained  unknown,  since  it  was  not  until 
1905  that  Schaudinn  and  Hoffmann^^  discovered  the  Tre- 
ponema pallidum. 

In  1903  Metchnikoff  and  Roux^^  published  their  experiment 
in  which  they  demonstrated  that  syphilis  could  be  trans- 
mitted to  chimpanzees.  This  afforded  an  opportunity  for 
direct  experimental  work  on  the  efficacy  of  prophylactics 
against  syphilis,  of  which  they  at  once  took  advantage.    These 


170  PERSONAL  PROPHYLAXIS 

experimental  results  were  published  in  1905,"  and  among 
them  were  the  following:  A  chimpanzee  was  inoculated  on 
both  eyebrows  with  a  virus  obtained  from  the  indurated 
chancres  of  two  persons.  Three-quarters  of  an  hour  after 
the  parts  were  rubbed  for  ten  minutes  with  mercurial  oint- 
ment (Hg.  100  gm.,  benzoated  lard  100  gm.).  This  treatment 
resulted  in  local  inflammation.  Syphilis  failed  to  develop, 
although  a  control  chimpanzee  inoculated  in  the  same  way 
with  the  same  virus  developed  chancres  on  both  eyebrows 
after  an  incubation  period  of  twenty-eight  days.  In  order  to 
prove  that  the  first  chimpanzee  was  not  infected,  and  also 
that  it  could  develop  syphilis,  a  second  inoculation  with 
human  virus  was  made  on  both  eyebrows  and  on  the  penis 
forty-nine  days  after  the  first  inoculation.  Thirty  days  after 
this  second  inoculation  (seventy-nine  days  after  the  first) 
a  typical  chancre  appeared  on  the  left  eyebrow  followed  by 
hypertrophy  of  the  glands,  and  two  chancres  appeared  on  the 
penis  nine  days  after  the  one  on  the  eyebrow,  with  inguinal 
adenitis.  About  a  month  later  a  mucous  patch  appeared 
on  the  upper  lip. 

Since  the  above  mercurial  ointment  was  found  to  be  rather 
irritating,  Metchnikoff  and  Roux  substituted  calomel  in 
later  experiments.  This  ointment  was  composed  of  10  parts 
of  calomel  and  20  parts  of  lanolin.  A  monkey  was  inoculated 
in  the  same  way  with  human  virus.  An  hour  after  the  inocu- 
lation the  two  eyebrows  were  rubbed  with  the  calomel 
ointment.  The  animal  remained  free  from  syphilis  for  more 
than  two  months,  although  an  untreated  control  monkey 
developed  a  typical  chancre  after  forty  days.  Two  months 
after  the  first  inoculation  the  first  monkey  was  again  inocu- 
lated and  twenty-four  days  later  presented  typical  chancres 
at  the  sites  of  inoculation;  thus  proving  that  it  was  sus- 
ceptible to  syphilis.  In  another  experiment  three  monkeys 
were  inoculated.  One  served  as  the  control  and  the  two 
others  received  local  treatment  with  calomel  ointment  one 
hour  after  the  inoculation.  The  control  monkey  developed 
typical  chancres  on  both  eyebrows  after  twenty-eight  days, 
while  the  monkeys  treated  with  calomel  ointment  remained 
well  for  sixty-eight  days.    Finally,  in  order  to  determine  how 


METHODS  TO  PREVENT  GENITAL  INFECTION     171 

long  the  syphilitic  virus  remained  localized,  they  inoculated 
the  ear  of  a  monkey.  Twenty-four  hours  later  the  part 
inoculated  was  removed.  This  monkey  remained  well  for 
sixty  days  after  this  inoculation  of  the  ear,  when  it  was 
inoculated  a  second  time  on  both  eyebrows.  These  later 
inoculations  resulted  in  typical  chancres.  The  authors 
concluded  that  the  virus  remains  localized  for  at  least 
twenty-four  hours. 

In  a  later  communication  published  in  1906,  Metchnikoff 
and  Roux^s  g^ate  that  having  tried  twelve  experiments  on 
monkeys    with    uniformly    satisfactory    results    they    next 
performed  the  experiment  on  a  man.    A  student  of  medicine 
offered  himself,  and  they  assured  themselves  that  he  had 
never    had    syphilis,    either    acquired    or    hereditary.      On 
February  1,  in  the  presence  of  Doctors  Queyrat,  Sabauraud, 
and  Salmon,  they  made  three  scarifications  on  the  left  side 
of  the  balanopreputial  fold  with  a  Vidal  scarificator  charged 
with  syphilitic  virus.    This  virus  had  just  been  taken  from 
an  indurated  chancre  of  the  penis  from  a  patient  in  the 
service  of  M.  Humbert.     This  chancre  was  of  two  months' 
duration    and  was   accompanied  by   inguinal  adenopathy. 
The  right  side  of  the  balanopreputial  fold  was  also  inoculated 
in  the  same  way  with  virus  obtained  from  a  chancre  of  nine 
or  ten  days'  duration.     The  second  source  of  virus  was  a 
patient  in  the  service  of  M.  Queyrat,  and  this  patient  also 
had  inguinal  adenopathy  and  had  received  no  treatment. 
The  same  vhus  was  inoculated  in  a  champanzee,  which,  how- 
ever, died  of  pneumonia  after  ten  days,  and  also  into  both 
eyebrows  of  four  macacus  monkeys.     An  hour  after  the 
inoculation  the  parts  inoculated  on  the  man  and  on  one 
monkey  were  rubbed  for  fifteen  minutes  with  the  30  per  cent, 
calomel  ointment.     Twenty  hours  after  the  inoculation  the 
eyebrows  of  the  second  monkey  were  rubbed  with  the  same 
ointment.     The  other  two  monkeys  were  left  as  controls. 
•  The  man  did  not  develop  syphilis,  though  watched  for  more 
than  three  months.    Seventeen  days  after  the  inoculation  the 
two  control  monkeys  that  were  not  treated  with  the  ointment 
both  developed  primary  lesions,  while  the  monkey  treated 
after  a  twenty-hour  interval  developed  a  chancre  after  thirty- 


172  PERSONAL  PROPHYLAXIS 

nine  days'  incubation.  It  is  interesting  to  note  that  the  subject 
of  this  experiment  was  Maisonneuve/^  who  pubhshed  this 
experiment  on  himself  as  part  of  his  thesis  for  the  doctorate. 

This  experiment  affords  direct  evidence  that  men  as  well 
as  apes  may  be  protected  from  syphilis  by  the  application 
of  calomel  ointment.  It  is  especially  important  to  note  that 
in  all  of  these  successful  experiments  the  prophylactic  calomel 
ointment  was  applied  one  hour  after  the  inoculation,  and  that 
while  there  is  evidence  that  the  syphilitic  virus  may  remain 
localized  for  twenty-four  hours,  or  that  it  does  not  gain  access 
to  the  systemic  circulation,  prophylaxis  applied  twenty  hours 
after  inoculation  failed  to  protect. 

These  experiments  of  Metchnikoff  and  Roux  attracted 
wide  attention  because  of  a  very  general  interest  in  the 
subject,  and  in  most  quarters  there  was  a  disposition  to  accept 
them  as  authoritative  and  a  definite  solution  of  the  problem 
of  prophylaxis  against  syphilis.  Calomel  ointment  was 
recommended  as  a  prophylactic  by  many  physicians,  and 
was  compounded  and  sold  for  the  same  purpose  by  many 
pharmacists. 

But  dissenting  voices  were  soon  raised  in  criticism,  directed 
at  supposed  errors  in  the  experimental  work,  calling  attention 
to  instances  in  which  calomel  ointment  failed  to  protect  in 
practice  and  condemning  the  method  as  immoral.  One  of 
the  earliest  of  these  critics,  Levy-Bing,^^  pointed  out  that  in 
regard  to  the  experiment  on  Maissonneuve  there  was  no 
scientific  proof  that  he  was  free  from  acquired  or  hereditary 
syphilis,  nor  was  it  absolutely  proved  that  he  was  not  infected. 
He  also  reported  one  of  the  first  cases  in  which  the  calomel 
ointment  failed  to  protect,  a  case  of  Gaucher's,  in  which 
exposure  occurred  May  19,  1906,  and  calomel  ointment  was 
used  immediately  after;  but  a  chancre  developed  on  June  13, 
and  on  July  17  the  patient  developed  a  generalized  macular 
eruption.  Levy-Bing  concluded  that  inunction  with  calomel 
ointment  may  not  afford  absolute  security  to  those  who  use 
it  even  when  it  is  applied  during  the  first  hours  following 
exposure.  Other  similar  cases  in  which  the  use  of  calomel 
ointment  failed  to  protect  were  soon  reported,  but  it  is  obvious 
that  these  occasional  failures  in  practice  do  not  invalidate 


METHODS  TO  PREVENT  GENITAL  INFECTION     173 

the  experiments  of  MetchnikofP  and  Roux.  The  experimental 
prevention  of  syphiHs  in  the  laboratory,  where  all  conditions 
are  rigidly  controlled,  is  one  thing;  the  prevention  in  general 
practice,  often  among  ignorant  people  and  with  conditions 
uncontrolled,  is  quite  another  thing.  These  two  phases  of  the 
subject  should  be  discussed  separately. 

The  only  really  serious  effort  to  refute  the  statements  of 
Metchnikoff  and  Roux  by  experimental  evidence  was  made  by 
Neisser,^^  who  stated  that  "The  categorical  statements  of 
Metchnikoff  are  contradicted  not  only  by  a  yriori  reason- 
ing, but  also  by  my  experiments  which  show  that  inunctions 
and  washes  do  not  regularly  prevent  infection."  Neisser's 
experiments  may  be  tabulated  as  follows: 

Infection  was  prevented  in  the  following  experiments: 

Acid  carbol.  pur 1  experiment 

Sublimate  solution  2  to  1000 4 

Sublimate  solution  3  to  1000 4  " 

Sol.  silver  nitrate,  5  per  cent 3 

Calomel  in  normal  saline 3 

Calomel,  30  per  cent,  in  vaseline 1 

Calomel,  10  per  cent,  with  soap 1 

Washing  with  water,  fifteen  minutes       ....  2 

Experiments  were  negative.    Infection  followed. 

Iodoform,  one  hour 2  experiments 

Ungt.  cinereum,  one  hour 1 

Ungt.  cinereum,  ten  minutes 2 

Sublimate  1  to  1000,  one  hour 1 

Calomel  and  salt  solution,  10  per  cent.,  one  hour  1  " 

Calomel,  10  per  cent,  water,  salve,  one  hour     .      .  1 

From  this  it  will  be  seen  that  in  Neisser's  experiments 
calomel  ointment,  30  per  cent.,  protected  in  the  only  experi- 
ment in  which  it  was  used.  Metchnikoff ^^  promptly  replied 
to  Neisser's  objections  and  pointed  out  that  Neisser  had 
only  used  10  per  cent,  calomel  ointment  while  he  had  used 
from  25  per  cent,  to  33  per  cent.  In  order  to  determine 
whether  less  than  this  amount  would  be  effective, 
Metchnikoff  inoculated  five  monkeys  from  a  chancre.  One 
hour  after  two  monkeys  were  rubbed  with  10  per  cent, 
calomel  ointment  in  lanolin  and  two  others  were  rubbed 


174  PERSONAL  PROPHYLAXIS 

with  20  per  cent,  calomel  ointment;  the  fifth  monkey  served 
as  a  control.  One  of  the  four  treated  monkeys  died  before 
the  end  of  the  experiment;  but  the  three  others  developed 
undeniable  chancres  after  the  proper,  period  of  incubation. 
Metchnikoff  stated  that  this  experiment  indicated  that  to 
be  effective  the  ointment  must  contain  at  least  25  per  cent, 
of  calomel,  and  he  recommended  33  per  cent.  He  reiterated 
his  belief  that  "Experiments  on  the  preventive  action  of 
mercurial  ointment  on  monkeys  are  sufficiently  numerous 
and  conclusive  to  form  the  basis  of  a  prophylaxis  against 
syphilis." 

Vorberg^^  thought  that  Neisser's  failures  to  protect  with 
calomel  ointment  were  to  be  explained  on  the  ground  that 
Neisser  inoculated  his  virus  too  deeply.  In  describing  his 
experiments,  Neisser  states  that  the  animals  were  deeply 
scarified  over  both  eyebrows  and  then  inoculated  with  the 
virus.  It  is  apparent  that  if  inoculations  are  made  in  such  a 
manner  that  the  virus  may  sometimes  gain  access  to  the 
general  circulation,  that  no  prophylactic,  however  efficacious 
against  treponemata  on  the  surface,  can  be  expected  to 
afford  protection  against  such  a  systemic  infection.  Metch- 
nikoff  in  his  experiments  made  inoculations  deeper  than 
those  likely  to  occur  in  natural  infections,  and  rightly  claimed 
that  experiments  of  this  character  should  be  made  to  conform 
as  nearly  as  possible  to  natural  conditions. 

However,  it  must  not  be  supposed  from  this  discussion 
that  Neisser  was  opposed  to  prophylaxis  against  syphilis. 
On  the  contrary  he  advocated  it,  and  his  opposition  was 
only  directed  against  the  use  of  calomel  ointment  because 
he  believed  a  solution  of  mercury  chloride  was  much  more 
effective.  Neisser  continued  his  experiments  in  collabora- 
tion with  Siebert,^^  stating  that,  with  the  discovery  of  the 
transmissibility  of  syphilis  to  apes,  experimental  investiga- 
tions on  personal  prophylaxis  were  placed  on  a  sound  basis. 
All  experiments  on  vaccination  or  immunization  have  failed ; 
and  consequently  all  prophylaxis  must  center  on  the  destruc- 
tion of  the  virus  at  the  port  of  entry. 

Various  disinfectants  were  first  tested  in  vitro,  the  method 
of  experiment  being  as  follows:    Syphilitic  apes  were  killed 


METHODS   TO  PREVENT  GENITAL  INFECTION     175 

and  the  spleen,  testicles  and  bone  marrow  ground  up  and 
emulsified.  This  mixture  furnished  a  rich  inoculation  mate- 
rial which  seldom  failed  to  inoculate  controls  with  syphilis. 
Certain  amounts  of  this  material  were  then  mixed  with  the 
disinfectant  to  be  tested,  and  after  a  varying  length  of  time 
this  mixture  was  injected  into  animals,  using  control  animals 
with  the  untreated  virus.  Many  experiments  of  this  char- 
acter were  performed;  but  for  our  purpose  it  suffices  to  note 
that  water  and  salt  solution  alone  were  shown  to  have  no 
deleterious  effect  upon  the  virus,  while  the  sublimate  solution 
gave  the  best  results,  a  solution  of  1  to  10,000  killing  all 
treponemata  in  fifteen  minutes.  Stronger  solutions  of  mer- 
curic chloride  (1  to  5000)  when  mixed  with  bloo.d  or  albumi- 
nous fluids  were  not  so  effective,  owing  to  the  combination 
of  the  mercury  with  the  albumin.  Thus  in  one  experiment 
in  which  the  virus  was  mixed  with  mercuric  chloride  solution, 
1  to  5000,  for  fifteen  minutes,  of  two  monkeys  inoculated, 
one  was  protected  but  the  other  developed  a  chancre. 
Calomel  and  calomel  oil  in  10  per  cent,  addition  to  the  virus 
was  also  effective.  The  calomel  oil  was  described  as  a  colloidal 
preparation  of  calomel  which  was  partly  soluble.  In  all, 
eight  monkeys  were  inoculated  with  virus  that  had  been 
mixed  with  10  per  cent,  calomel.  All  remained  free  from 
syphilis,  showing  that  even  insoluble  calomel  has  in  vitro 
a  definite  lethal  action  on  the  treponema. 

Disinfection  experiments  on  apes  w^ere  next  undertaken. 
These  experiments  were  divided  into  two  classes,  in  one  of 
which  disinfection  was  attempted  by  fluids  and  in  the  other 
by  salves.  The  animals  were  deeply  scarified  over  both 
eyebrows  and  then  inoculated  with  the  virus  above  described. 
After  a  given  length  of  time  the  disinfecting  agent  was 
applied.  In  all  52  experiments  were  performed,  using  various 
antiseptics.  Out  of  three  experiments  in  which  mercuric 
chloride  solution,  1  to  1000,  was  used  one  hour  after  inocula- 
tion two  monkeys  developed  chancres.  Of  four  experiments 
using  mercuric  chloride,  1  to  500  solution  applied  one  hour 
after  inoculation,  all  four  remained  uninfected.  Mercuric 
chloride,  1  to  500  with  20  per  cent,  glycerin,  was  then  tested. 
It  was  applied  to  five  monkeys  fifteen  minutes  after  inocula- 


176  PERSONAL  PROPHYLAXIS 

tion;  to  three  monkeys  three  hours  after  inoculation;  to  one 
monkey  after  six  hours,  and  to  two  monkeys  after  twenty- 
four  hours.  All  of  these  monkeys  remained  free  from 
syphilis. 

In  regard  to  calomel  ointment  a  smaller  number  of  experi- 
ments were  performed.  Four  monkeys  were  inoculated  and 
treated  fifteen  minutes  after  by  a  mixture  of  calomel  in  salt 
solution.    All  four  monkeys  were  protected. 

Four  monkeys  were  inoculated  and  treated  with  10  per 
cent,  calomel  ointment  one  hour  later;  all  four  were  infected. 
(It  is  to  be  noted  that  Metchnikoff's  monkeys  were  also 
infected  when  he  used  10  per  cent,  calomel  ointment.) 

Three  monkeys  were  inoculated  and  treated  with  a  33  per 
cent,  calomel  ointment  in  water  and  lanolin.  Two  were 
protected  and  one  was  infected.  Neisser  concluded  that  the 
attempts  at  disinfection  with  salves  were  unsuccessful,  and 
an  investigation  was  undertaken  to  determine  the  cause  of 
this  failure. 

To  an  unprejudiced  outsider  it  would  appear  that  Neisser 
was  hardly  fair  in  this  controversy.  He  tried  all  sorts  of 
antiseptics,  but  made  only  three  experiments  with  calomel 
ointment  made  up  in  the  proportion  recommended  by 
Metchnikoff.  Of  these  three  experiments  we  may  say  that 
they  were  more  successful  than  the  three  in  which  mercuric 
chloride  solution,  1  to  1000,  was  used.  Two  out  of  three 
experiments  in  which  calomel  ointment  was  used  resulted 
successfully  in  protecting  the  animals,  while  only  one  out 
of  three  in  which  mercuric  chloride,  1  to  1000,  was  used 
resulted  in  protection.  1  to  1000  is  quite  as  strong  as  mer- 
curic chloride  can  be  used  in  practice,  and  therefore  the 
experiments  in  which  1  to  500  mercuric  chloride  were  used 
as  well  as  the  numerous  failures  of  salves  made  with  other 
antiseptics  than  mercury  are  beside  the  point.  Neisser 
had  started  with  a  preconceived  opinion  as  to  the  relative 
value  of  mercuric  chloride  solution  and  calomel  ointment, 
and  if  his  experiments  did  not  bear  out  his  opinion,  so  much 
the  worse  for  the  experiments. 

Neisser  thought  that  calomel  ointment  was  not  as  effective 
as  sublimate  solution  for  the  following  reasons : 


METHODS  TO  PREVENT  GENITAL  INFECTION     111 

1.  Because  of  the  comparatively  slight  disinfectant  action 
of  calomel  as  such. 

2.  This  activity  is  much  further  reduced  because  of  its 
incorporation  in  a  fatty  salve. 

3.  All  fatty  salves  adhere  badly  to  eroded,  wet  and  bleed- 
ing surfaces. 

He  recommended  a  prophylactic  composed  of  amylum, 
tragacanth  gelatin  and  mercuric  chloride,  for  which  he 
claimed  the  following  advantages : 

1.  The  active  constituent,  mercuric  chloride,  is  a  powerful 
disinfectant. 

2.  In  this  compound  the  action  of  the  bichloride  is  not 
affected  or  diminished. 

3.  This  preparation  adheres  well  to  damp  and  bleeding 
surfaces. 

4.  It  is  innocuous  even  after  it  has  remained  on  the  geni- 
talia for  twenty-four  hours. 

5.  It  has  prevented  infection  in  nine  out  of  eleven  experi- 
ments. 

This  practically  concludes  the  experimental  work  upon 
which  the  prophylaxis  of  syphilis  is  based.  There  are  a  few 
other  experiments  scattered  through  the  literature,  such  as 
those  of  Hugel,^^  but  these  are  inconclusive  and  of  little 
value. 

Thus  we  are  naturally  led  to  a  discussion  of  the  relative 
value  of  unguents  and  fluid  disinfectants  as  prophylactic 
agents.  Koch^^  found  that  carbolic  acid  in  an  oily  solution 
lost  its  disinfectant  power.  Spores  remained  alive  and 
virulent  in  5  per  cent,  carbol  oil  for  at  least  110  days;  and 
bacilli  remained  alive  at  least  four  days  in  this  fluid. 
Wolfhligel  and  von  Knorre^^  showed  that  this  loss  of  disin- 
fectant power  is  due  to  the  fact  that  carbolic  acid  in  water 
solution  is  dissolved  out  by  oil  much  more  easily  than 
carbolic  acid  in  oily  solution  can  be  dissolved  out  by  water. 
This  is  apparently  due  to  the  powerful  affinity  which  oil 
possesses  for  carbolic  acid,  and  the  inactivity  of  carbolic 
acid  in  oily  solution  is  due  largely  to  the  fact  that  the  watery 
plasma  of  the  bacterial  cell  cannot  abstract  the  carbolic  acid 
from  the  oil.  It  is  evident  therefore  that  in  an  ointment 
12 


178  PERSONAL  PROPHYLAXIS 

made  up  of  carbolic  acid  and  vaselin,  a  preparation  frequently 
used,  the  carbolic  acid  will  have  lost  much  of  its  disinfectant 
power. 

But  there  is  a  fundamental  difference  between  antiseptics 
soluble  in  fat  and  those  that  are  insoluble  and  simply  form 
a  mixture.  Gottstein^^  found  that  fat-soluble  antiseptics 
mixed  with  lanolin  follow  Koch's  law  and  are  inactive. 
In  experiments  in  which  salves  of  5  per  cent,  carbolic  acid, 
thymol  and  menthol  were  used  and  mixed  with  a  fluid  cul- 
ture of  prodigiosus,  plates  after  five  minutes,  one  hour  and 
twenty-four  hours,  showed  that  unrestrained  growth  occurred. 
But  a  salve  of  sublimate  lanolin  acted  quite  differently,  and 
Gottstein  asserts  that  it  is  as  active  a  disinfectant  as  a, watery 
solution  of  sublimate.  Threads  carrying  anthrax  spores 
were  treated  with  sublimate  lanolin  and  introduced  under 
the  skin  of  animals.  These  animals  lived,  although  control 
animals  in  which  the  threads  were  treated  with  lanolin  alone 
or  with  lanolin  mixed  with  balsam  of  Peru  died  of  anthrax. 
Thus  a  body  like  mercuric  chloride  which  has  a  greater 
solubility  affinity  for  water  than  for  oil  maintains  its  dis- 
infectant properties  in  a  fatty  salve  emulsion,  while  every 
substance  possessing  a  greater  solubility  affinity  for  fats  than 
for  water  loses  its  disinfectant  properties  in  fats. 

This  subject  was  again  investigated  experimentally  by 
Breslauer.^^  Fluid  cultures  of  various  organisms  were  made 
and  glass  slides  were  immersed  in  them  and  then  dried. 
These  slides  were  then  placed  in  the  salves  to  be  tested  for 
various  periods,  and  after  removal  were  washed  twice  with 
ether  and  placed  in  bouillon,  which  was  watched  fourteen 
days  for  growth.  Breslauer  found  that  all  the  salves  tested 
had  disinfectant  properties,  but  that  salves  in  which  lanolin 
and  unguentum  leniens  were  used  were  much  more  active 
than  salves  in  which  other  fats  were  used.  Official  lanolin 
was  much  more  active  than  anhydrous  lanolin.  His  con- 
clusion was  that  the  disinfectant  power  of  a  salve  depended 
largely  on  the  water  content  of  the  base  used. 

From  these  considerations  it  appears  that  Neisser  was 
wrong  in  his  belief  that  calomel  would  lose  its  disinfectant 
power  when  incorporated  in  a  salve.     For  while  calomel 


METHODS  TO  PREVENT  GENITAL  INFECTION     179 

is  but  slightly  soluble  in  water  it  is  not  soluble  at  all  in  the 
fats  used  for  salves.  It  is  also  clear  that  Metchnikoff's 
original  recommendation  that  the  salve  should  be  prepared 
with  lanolin  should  be  followed,  since  because  of  its  water 
content  the  calomel  will  be  more  active  in  this  base.  It  may 
be  further  pointed  out  that  when  such  an  ointment  is  pre- 
pared, using  an  insoluble  or  comparatively  insoluble  sub- 
stance, great  care  must  be  taken  in  the  incorporation  of  the 
ingredients.  For  although  the  dry  medicament  is  finely 
divided  in  a  fatty  base  there  must  necessarily  remain  "dead 
points"  in  the  spaces  between  the  particles  of  medicament. 
The  more  thorough  the  mixtiu-e  and  subdivision  of  the 
powder  the  smaller  are  the  dead  points.  And  the  greater 
the  amount  of  water  in  the  base  the  greater  is  the  tendency 
of  the  drug  to  become  soluble  and  so  diminish  the  dead 
points. 

We  may  therefore  conclude  that  a  calomel  ointment  to 
be  effective  must  contain  33  per  cent,  of  calomel,  should  be 
incorporated  in  lanolin  as  a  base  and  that  great  care  should 
be  taken  in  its  preparation  to  ensure  thorough  mixing.  No 
doubt  many  failures  of  this  agent  in  actual  practice  and  even 
in  some  experiments  may  be  attributed  to  ignorance  or 
negligence  on  the  part  of  the  pharmacist  in  not  following 
these  directions. 

A  solution  of  mercuric  chloride,  1  to  1000,  or  salves  made 
of  sublimate  in  the  same  proportion  are  undoubtedly  more 
active  disinfectants  than  calomel  in  any  form.  On  the 
other  hand,  mercuric  chloride  is  subject  to  several  serious 
objections.  It  is  not  nearly  so  effective  a  disinfectant  in 
practice  as  in  theory  because  of  its  well-known  tendency 
to  combine  with  albumin,  and  the  danger  of  poisoning 
following  absorption  or  accidental  ingestion  is  by  no  means 
inconsiderable.  Such  accidents  occur  with  sufficient  fre- 
quency to  warrant  the  condemnation  of  mercuric  chloride 
as  a  prophylactic  agent  on  this  ground  alone.  Furthermore, 
if  used  in  solution,  it  quickly  dries  and  its  disinfectant  action 
is  brief  in  duration,  while  calomel  ointment  may  remain 
applied  for  hours  so  that  continuous  local  action  is  obtained 
and  perhaps  even  some  degree  of  absorption  attained. 


180  PERSONAL  PROPHYLAXIS 

For  all  these  reasons  calomel  ointment  is  believed  to  be 
preferable  to  mercm*ic  chloride  in  any  form  as  a  prophylactic 
against  syphilitic  infection,  though  it  cannot  be  denied  that 
such  a  preparation  as  that  recommended  by  Neisser  would 
not  be  so  dangerous  as  a  solution  of  sublimate,  and  did  prove 
fairly  effective  in  his  hands.  The  objection  that  Neisser 
raises  against  an  ointment,  namely,  that  it  adheres  badly  to 
wet  and  bleeding  surfaces,  is  purely  theoretical.  In  practice 
no  difficulty  is  experienced  on  this  score,  particularly  when 
the  patient  follows  directions  as  to  careful  ablution  with 
soap  and  water  followed  by  drying  before  applying  the 
ointment. 

It  may  be  safely  concluded  that  laboratory  experiments 
have  demonstrated  that  syphilitic  infection  may  usually  be 
prevented  by  means  of  this  prophylactic  ointment  if  it  is 
applied  reasonably  early  after  exposure.  Since  Metchnikoff 's 
experiments  were  uniformly  successful,  and  since  Neisser's 
experiments  are  open  to  criticism  as  indicated  above,  we  may 
possibly  infer  that  with  a  proper  technic,  syphilitic  infection 
may  always  be  prevented  by  the  use  of  this  ointment  in 
laboratory  experiments. 

It  next  becomes  necessary  to  determine  what  results  have 
followed  the  use  of  this  prophylactic  in  actual  practice. 
This  subject  may  be  discussed  under  two  heads:  (1)  isolated 
instances  either  followed  by  success  or  failure,  and  (2)  the 
statistics  indicating  the  success  or  failure  of  the  method  when 
it  has  been  in  use  by  large  bodies  of  men,  such  as  soldiers  or 
sailors. 

Isolated  Instances. — One  of  the  first,  related  by  Metch- 
nikoff,^^  was  a  patient  of  Dr.  Picquet.  A  young  man 
passed  the  night  with  a  woman  and  in  the  morning  found 
an  erosion  on  his  penis.  Before  noon  the  girl  was  examined 
and  found  to  have  numerous  mucous  patches  on  the  vulva 
and  in  the  throat,  with  adenopathy  and  other  evident  signs 
of  actively  contagious  syphilis.  At  4  p.m.  the  man  rubbed 
his  penis  with  25  per  cent,  calomel  ointment,  which  was 
allowed  to  remain  for  forty-eight  hours.  This  man  remained 
absolutely  free  from  infection,  and  the  doctor  who  knew 
the  man  well  stated  that  he  had  never  had  acquired  or  heredi- 


METHODS   TO  PREVENT  GENITAL  INFECTION     181 

tary  syphilis.  Metchnikoff  states  that  this  observation  may 
be  compared  with  a  laboratory  experiment. 

It  is  indeed  probable  that  if  the  ointment  had  not  been 
used  the  erosion  on  the  penis  would  have  served  as  the  portal 
of  entry  for  the  syphilitic  virus.  But  we  must  admit  that 
because  a  given  individual  is  not  infected  after  coitus  with 
an  infected  woman,  followed  by  the  use  of  calomel  ointment, 
this  does  not  constitute  proof  of  the  action  of  the  calomel 
ointment.  For  even  syphilis  is  not  invariably  contagious, 
and  some  people  probably  escape  it  after  being  exposed 
without  the  use  of  any  prophylactic,  a  fact  soon  pointed  out 
by  Gaucher,^"  Gerson^^  and  others. 

This  objection  loses  its  force,  however,  with  the  multipli- 
cation of  such  instances,  for  if  a  large  number  of  individuals 
are  protected  after  exposure  to  women  known  to  be  syphilitic 
we  cannot  assume  that  they  would  all  have  escaped  infection 
had  they  used  no  prophylactic.  There  are  numerous  such 
cases  in  the  literature,  all  of  which  cannot  be  quoted  at  length. 
Bonnet^^  reported  a  considerable  number  of  cases  in  which 
gray  mercurial  ointment,  calomel  ointment  or  even  vaselin 
alone  were  used  with  success  in  preventing  the  development 
of  syphilis.  Among  these  observations  there  were  seven  in 
which  intercourse  occurred  with  women  having  at  the  time 
active  and  highly  infectious  secondary  lesions.  In  several 
of  these  cases  the  dangerous  intercourse  was  repeated  a 
number  of  times  on  different  occasions,  and  in  two  of  the 
observations  in  which  the  use  of  calomel  ointment  prevented 
the  development  of  syphilis  in  the  man  that  used  it  the 
infectiousness  of  the  lesions  in  the  woman  was  demonstrated 
by  the  infection  of  other  men  who  were  exposed  at  about 
the  same  time  but  did  not  use  any  prophylactic.  Thus  in 
one  observation  three  friends  consorted  with  the  same 
woman,  but  the  only  one  to  develop  a  chancre  was  the  one 
who  refused  to  use  the  mercurial  ointment,  which  the  other 
two  used  profusely. 

A  very  interesting  case  was  reported  by  Wolbarst.^^  On 
May  2,  1908,  he  was  called  to  treat  "A,"  a  young  man,  aged 
twenty-two  years,  single,  with  a  negative  venereal  history. 
"A"  and  a  friend  "B"  had  spent  the  night  with  a  woman 


182  PERSONAL  PROPHYLAXIS 

who  they  discovered  later,  by  her  own  admission,  was  suffer- 
ing from  active  syphihs.  Both  "A"  and  "B"  had  copulated 
several  times  during  the  night  and  the  chances  of  infection 
were  as  good  as  they  could  possibly  be.  "B"  had  caught  a 
train  for  the  West.  "A"  was  treated  with  calomel  ointment 
(30  per  cent,  in  lanolin) ,  which  was  rubbed  in  for  five  minutes 
within  six  hours  after  his  first  exposure.  The  woman  was 
brought  in  and  the  examination  showed  that  she  had  papules 
on  the  labia,  condylomata  about  the  anus  and  specific 
ulceration  about  the  tongue  and  lips.  For  three  weeks 
"A"  reported  every  other  day,  with  negative  results.  On 
June  3  he  brought  friend  "B,"  who  had  a  typical  indurated 
chancre  on  the  coronal  sulcus,  followed  in  a  few  weeks  by  an 
unmistakable  papular  eruption,  which  disappeared  under 
mercurial  treatment.  "A"  was  observed  for  more  than  four 
months  and  remained  free  from  syphilis.  We  have  here 
these  ideal  conditions— simultaneous  and  repeated  exposure 
of  two  susceptible  young  men  to  the  same  syphilitic  virus. 
One  man  receives  prophylactic  treatment  within  six  hours 
and  escapes  the  disease,  while  the  other  is  not  treated  and 
develops  syphilis,  thus  acting  as  a  control. 

The  above  instances  are  as  convincing  as  laboratory 
experiments,  and  taken  with  the  laboratory  experiment  on 
Maissonneuve,  they  afford  convincing  evidence  that  syphi- 
litic infection  may  often  be  prevented  by  the  use  of  calomel 
ointment. 

But  it  must  not  be  expected  that  this  prophylactic  will  be 
invariably  successful  when  used  under  the  ordinary  circum- 
stances attending  exposure.  Butte^  reported  5  cases  in 
which  "he  had  occasion  to  listen  to  the  plaints  of  those  who 
developed  chancres  in  spite  of  the  use  of  calomel  ointment," 
though  he  states  that  in  only  2  of  these  cases  was  he  con- 
vinced that  the  method  w^as  exactly  followed  and  the  oint- 
ment well  prepared.  Gaucher^"  also  reported  two  failures 
and  Carle^^  reported  three. 

The  list  of  such  failures  might  be  considerably  extended, 
but  it  would  be  to  no  purpose.  They  do  not  indicate  that 
calomel  ointment  is  not  an  efficient  prophylactic,  but  merely 
that  we  cannot  expect  that  it  will  be  invariably  successful 


METHODS  TO  PREVENT  GENITAL  INFECTION    183 

in  practice.  To  determine  just  what  may  be  expected  of  this 
prophylactic  in  practice  we  must  consult  the  statistics 
afforded  by  considerable  bodies  of  men  who  have  used  it 
for  certain  periods  of  time. 

While  there  is  no  dearth  of  literature  on  this  subject,  real 
facts  and  figures  are  very  difficult  to  obtain.  With  rare 
exceptions  those  who  have  introduced  the  use  of  the  pro- 
phylactic among  troops  or  other  large  bodies  of  men  are 
enthusiastic  in  regard  to  the  results  obtained,  but  the 
figures  and  statements  they  present  would  hardly  serve  to 
convince  the  critical.  It  must  be  remembered,  however, 
that  this  subject  is  one  concerning  which  it  is  almost  impos- 
sible to  collect  accurate  statistics,  and  since  the  consensus 
of  opinion  as  to  the  value  of  the  prophylactic  is  very  general 
this  fact  should  carry  some  weight.  The  following  may  be 
quoted  as  examples  of  the  literature  on  this  subject: 

Acevedo,^^  in  1908,  reported  the  results  following  the 
application  of  prophylaxis  in  the  Chilean  navy.  The  pro- 
phylaxis consisted  of  washing  with  soap  and  water  followed 
by  1  to  1000  bichloride  solution  for  fifteen  minutes,  and 
thereafter  the  application  of  an  ointment  of  red  oxide  of 
mercury.  1435  treatments  were  recorded  following  exposures 
in  ports  all  over  the  world,  including  Cape  Town,  Algiers, 
Malta,  Colombo,  Shanghai,  Yokohama,  San  Francisco  and 
Valparaiso.  Out  of  this  considerable  number  of  treatments 
only  3  cases  developed  syphilis.  While  such  an  observation 
is  uncontrolled  in  many  respects  it  would  seem  probable 
that  there  would  have  been  a  much  greater  percentage  of 
syphilitic  infections  among  sailors  under  these  circumstances 
had  no  prophylactic  been  used. 

Feistmantel,^**  in  1905,  divided  the  soldiers  of  the  Budapest 
garrison  into  four  groups:  The  first  group  received  pastilles 
of  potassium  permanganate,  the  second  group  used  a  solu- 
tion of  potassium  permanganate  in  barracks,  the  third  group 
used  a  wash  of  1  to  1000  bichloride  solution  and  the  fourth 
group  used  simply  soap  and  water.  No  reduction  in  venereal 
disease  was  observed  in  the  fourth  group,  but  Feistmantel 
claimed  that  in  the  other  three  groups  only  those  were 
infected  who  failed  to  apply  the  prophylactic  or  who  used  it 


184  PERSONAL  PROPHYLAXIS 

later  than  three  hours  after  exposure.  He  claimed  by  this 
method  to  have  reduced  the  incidence  of  venereal  disease 
from  57.6  per  thousand  to  21.8  per  thousand.  These  figures, 
however,  include  the  reduction  in  gonorrhea  and  chancroids, 
and  afford  very  little  information  with  regard  to  prophylaxis 
against  s^^philis. 

Tandler  (quoted  by  Neisser^^)  observed  a  great  reduction 
in  the  number  of  syphilitic  infections  among  a  detachment 
of  troops  following  the  introduction  of  a  prophylactic  wash 
of  1  to  1000  bichloride  solution.  Of  1560  exposures  followed 
by  this  prophylactic  only  three  men  developed  syphilis,  a 
considerable  diminution  in  the  previous  proportion  of 
syphilitic  infections  in  that  command. 

Michels"  reports  an  attempt  to  protect  the  crew  of  a 
commercial  ship  from  venereal  disease  while  at  Yokohama. 
He  states  that  he  could  usually  estimate  that  after  leaving 
Yokohama  at  least  5  per  cent,  of  the  crew  would  develop 
venereal  disease.  The  men  were  given  small  flasks  containing 
5  c.c.  of  fresh  10  per  cent,  protargol  solution,  together  with 
vaselin  and  sublimated  soap.  Before  coitus  the  men  were 
supposed  to  place  a  few  drops  of  protargol  in  the  urethra 
and  to  use  the  vaselin.  After  coitus  they  were  to  wash  with 
the  sublimate  soap  and  water  and  again  place  a  few  drops 
of  protargol  in  the  urethra.  The  200  men  were  in  Yokohama 
nine  days,  and  as  the  result  of  the  introduction  of  this  pro- 
phylactic not  a  single  case  of  gonorrhea  or  chancroid  devel- 
oped. One  man  developed  a  chancre  and  secondaries,  but 
he  had  been  exposed  twice,  and  admitted  that  on  the  second 
occasion  he  forgot  his  prophylactic  and  left  it  on  the  boat. 

Wickes^^  described  in  1908  his  experience  with  prophylaxis 
in  the  United  States  navy.  This  prophylaxis  consisted  of 
washing  with  green  soap  and  water,  followed  by  a  sublimate 
solution  of  1  to  2000  and  an  inunction  of  a  50  per  cent, 
calomel  ointment  in  lanolin,  which  was  allowed  to  remain 
all  day  with  a  protective  dressing.  While  in  Canton,  a 
heavily  infected  locality,  this  treatment  was  at  first  optional. 
But  owing  to  the  lack  of  interest  and  the  irresponsibility 
of  members  of  the  crew,  30  cases  of  primary  syphilis  devel- 


METHODS  TO  PREVENT  GENITAL  INFECTION     185 

oped  during  five  montlis  spent  in  that  port.  Compulsory 
prophylaxis  was  then  adopted,  and  subsequently  there  were 
922  shore  liberties  in  infected  Chinese  ports  and  426  pro- 
phylactic treatments.  No  case  of  primary  syphilis  developed 
on  this  ship  under  this  system  for  five  months,  at  the  end  of 
which  time  the  article  was  written. 

Siebert^^  conducted  observations  in  the  German  navy 
at  foreign  ports,  where  the  circumstances  were  such  that 
an  infection  might  not  unreasonably  be  expected  at  each 
exposure.  The  prophylaxis  against  syphilis  consisted  of 
washing  with  sublimate  solution  and  laying  a  strip  of  gauze 
soaked  in  sublimate  solution  around  the  sulcus  coronarius. 
The  number  of  individuals  infected  ranged  from  1  to  2  per 
cent.,  including  all  infections,  which  under  the  circum- 
stances Siebert  thought  was  a  brilliant  example  of  the  value 
of  prophylaxis.  Unfortunately  he  gives  no  figiues  to  indicate 
the  number  of  infections  with  syphilis. 

Venereal  prophylaxis  has  been  in  general  use  in  the  United 
States  army  and  navy  since  about  1908,  and  since  1912  the 
use  of  prophylactics  has  been  compulsory  in  the  army.  If 
careful  records  had  been  kept  in  regard  to  the  many  thous- 
and prophylactic  treatments  so  given  the  results  obtained 
would  be  apparent.  This  has  not  been  done,  no  doubt 
partly  from  a  desire  to  avoid  publicity;  but  many  officers 
have  published  their  opinions,  for  the  most  part  favorable, 
and  a  few  have  furnished  some  statistics,  among  which  the 
following  may  be  mentioned: 

Davidson^"  reported  320  prophylactic  treatments,  with 
no  infections  among  those  using  the  prophylactic,  although 
three  infections  occurred  among  those  not  using  the  pro- 
phylactic. 

Ledbetter^i  wrote,  in  1913,  "In  my  opinion  venereal 
prophylaxis  has  advanced  well  beyond  the  experimental 
stage,  and  it  is  of  great  value  and  importance  when  properly 
carried  out.  It  is  quite  true  that  adverse  reports  have  been 
made  by  some  of  the  medical  officers  of  the  navy  and  that 
others  have  no  faith  in  the  efficacy  of  the  method.  Personally, 
I  believe  that  the  negative  results  noted  in  the  adverse  reports 


186  PERSONAL  PROPHYLAXIS 

were  due  to  faulty  technic  or  to  lack  of  interest  on  the  part 
of  the  medical  officer,  and  that  in  consequence  the  method 
was  condemned  without  a  fair  trial.  It  is  not  enough  to 
institute  prophylaxis  and  then  to  take  only  a  perfunctory 
interest  in  it  thereafter.  The  medical  officer  must  take  an 
intense  personal  interest  in  the  work,  and  thus,  by  his  example, 
his  assistants  will  be  stimulated  to  put  forth  their  best 
efforts." 

The  above  is  the  opinion  of  the  majority  of  the  medical 
officers  of  the  army  and  navj'^,  and  is  reflected  in  the  tone 
of  the  reports  of  the  Surgeon-Generals.  Ledbetter  reported 
the  results  obtained  at  Cavite,  P.  I.,  for  eighteen  months. 
The  method  used  was  as  follows :  The  parts  were  thoroughly 
washed  with  green  soap  and  water,  10  per  cent,  solution  of 
argyrol  was  injected  into  the  urethra  and  retained  for  about 
half  a  minute,  and  33  per  cent,  calomel  ointment  was  then 
rubbed  in  well  and  allowed  to  remain  for  at  least  two  hours, 
being  covered  with  a  protective  dressing.  Ledbetter  says 
that  before  instituting  this  method  the  percentage  of  venereal 
infections  was  very  high,  amounting,  as  a  rule,  to  25  to  30  per 
cent,  of  all  admissions.  After  prophylaxis  was  begun  there  was 
an  immediate  drop  in  the  admission  rate,  and  the  average  for 
the  following  year  was  as  follows:  Gonorrhea  was  reduced 
from  20  to  25  per  cent,  of  the  total  admissions  to  8  per  cent., 
which  include  some  30  patients  who  did  not  report  for  the 
prophylaxis;  chancroid  was  reduced  from  3  to  5  per  cent,  of  the 
total  admissions  to  about  2  per  cent.,  including  10  patients  who 
did  not  report  for  treatment;  syphilis  was  reduced  from  about 
20  cases  per  annum  to  1  case,  and  this  man  did  not  take  the 
prophylactic. 

Ashford  reported*^  221  prophylactic  treatments,  of  whom 
2  men  developed  syphilis.  One  of  these  men  took  the  pro- 
phylactic fourteen  hours  after  exposure  and  1  man  eight 
hours  after  exposure. 

Cottle*^  reported  an  instance  in  which  of  560  men  on  a 
cruise  516  took  the  prophylactic  treatment  4897  times 
during  eleven  months,  while  44  by  not  taking  treatment 
denied  exposure.     Some  of  these  44  did  expose  themselves 


METHODS  TO  PREVENT  GENITAL  INFECTION     187 

because  3  developed  gonorrhea.  Out  of  this  large  number 
of  exposures  only  17  men  developed  syphilis,  and  the  his- 
tories in  the  majority  of  these  cases  showed  that  the  prophy- 
lactic was  taken  as  late  as  ten,  eighteen  and  twenty  hours 
after  exposure.  The  great  majority  of  admissions  followed 
the  few  long  liberties  when  the  prophylactic  was  given 
late. 

About  the  best  article  on  this  subject  is  by  Riggs,^*  who 
records  5103  prophylactic  treatments  with  only  81  infections, 
as  shown  by  the  following  table.  The  prophylactic  used 
consisted  of  an  injection  of  a  silver  salt  of  moderate  strength 
and  the  use  of  33  per  cent,  calomel  ointment. 

Hours  sub-  Number  Number  Per  cent, 

sequent  to  of  of  of 

exposure.  treatments.       infections.        infections. 

1 1180  1  0.08 

2 1172   ■  7  0.59 

3 521  4  0.77 

4 330  2  0.61 

5 199  3  1.57 

6 321  5  1.58 

7 277  6  2.27 

8 390  16  4.22 

9 283  10  3.62 

10 214  11  5.14 

More  than  10 216  16  7.40 

Total 5103       81       1.58 

The  above  table  indicates  the  efficiency  of  medical  pro- 
phylactic treatment,  particularly  if  administered  within  a 
few  hours  subsequent  to  exposure.  It  must  be  remembered 
that  this  table  gives  all  infections,  but  in  a  previous  article^^ 
Riggs  states  that  out  of  3556  prophylactic  treatments  there 
were  only  67  infections,  and  of  these  only  8  were  cases  of 
syphilis. 

Exner*^  gives  the  following  record  of  prophylactic  treat- 
ments and  the  venereal  cases  of  a  regiment  of  regulars  for 
nearly  two  and  a  half  years.  Unfortunately  these  figures  give 
no  information  as  to  the  relative  number  of  cases  among  the 
men  who  took  the  prophylaxis  as  compared  with  the  cases 
developing  among  men  who  were  exposed,  but  w^ho  disobeyed 
orders  and  failed  to  take  the  prophylaxis,  and,  moreover,  the 


188  PERSONAL  PROPHYLAXIS 

figures  for  infections  include  all  venereal  diseases,  so  that  no 
direct  evidence  is  given  in  regard  to  the  efficacy  of  this  treat- 
ment in  preventing  syphilis.  But  in  comparing  the  venereal 
rate  with  the  amount  of  indulgence,  as  indicated  by  the  pro- 
phylactic treatments  alone,  it  will  be  seen  that  the  rate  is 
very  low,  and  we  cannot  escape  the  conclusion  that  venereal 
prophylaxis  as  carried  out  in  certain  parts  of  the  army  is 
quite  effective. 

Month  and  Strength  of 

year.  regiment. 

May,  1914 827 

June,  1914 757 

July,  1914 700 

August,  1914 684 

September,  1914 726 

November,  1914 824 

December,  1914 788 

January,  1915 723 

February,  1915 653 

March,  1915 744 

April,  1915 791 

May,  1915 788 

June,  1915 793 

July,  1915 811 

August,  1915 841 

September,  1915 839 

October,  1915 840 

November,  1915 815 

December,  1915 800 

January,  1916 '833 

February,  1916 940 

March,  1916 927    ■ 

April,  1916 921 

May,  1916 913 

June,  1916 900 

July,  1916 901 

August,  1916 1004 

September,  1916 1068 

October,  1916 1046 

I  have  a  number  of  reports  on  the  use  of  the  prophylactic 
in  the  army  that  have  been  sent  to  me  through  the  kindness 
and  interest  of  various  medical  officers,  of  which  the  following 
may  serve  as  examples:  Record  of  prophylactic  treatments 
during  the  month  of  September,  1915,  at  Fort  Mills,  P.  I., 
and  sent  through  the  courtesy  of  Major  Robert  Skelton,  M.  C. : 


Number  of 
prophylactic 
treatments. 

Venereal 
cases. 

53 

1 

103 

7 

146 

4 

178 

0 

196 

0 

227 

2 

151 

1 

278 

3 

379 

0 

.354 

4 

397 

4 

678 

3 

663 

2 

657 

5 

523 

5 

490 

9 

332 

8 

305 

6 

350 

8 

402 

11 

450 

5 

370 

5 

405 

8 

450 

4 

285 

3 

372 

5 

280 

9 

420 

5 

450 

18 

METHODS  TO  PREVENT  GENITAL  INFECTION     189 

Time  between  Total  number 

exposure  and                                                    taking  Number  Number 

prophylactic.                                             prophylactic.  protected.  unprotected. 

1  hour 332  325  7 

2  " 151  148  3 

3  " 25  24  1 

4  " 6  6  0 

5  " 5  5  0 

6  " 5  5  0 

8     " 1  1  0 

Over  10  hours 56  52  4 

No  time  stated 4  4  0 

Total 585  570  15 

Of  the  15  cases  that  developed  disease  only  1  contracted 
syphilis,  while  among  the  men  who  failed  to  take  the  pro- 
phylactic during  the  same  time,  4  developed  syphilis.  It  is 
believed  that  this  represents  about  the  average  results 
obtained  throughout  the  army.  It  will  be  noticed  that  the 
majority  of  failures  are  among  the  men  taking  the  prophy- 
lactic during  the  first  and  second  hours  after  exposure,  which 
is  to  be  explained  on  the  basis  that  the  men  often  do  not  tell 
the  truth  about  the  time  of  exposure,  and  this  is  one  of  the 
great  difficulties  in  obtaining  accurate  records  of  this  work. 

Major  Royal  Reynolds  very  kindly  sent  me  the  records 
of  his  organization  from  Nogales,  Arizona,  from  June  1, 
1915,  to  June  30,  1916.  The  strength  of  the  command  for 
the  period  was  866,  and  4989  prophylactic  treatments  were 
given.  There  was  no  record  of  syphilitic  infection  following 
any  of  these  treatments  and  the  sick  rate  for  syphilis  during 
the  year  was  only  1.27  per  cent.,  while  for  the  army  as  a 
whole  it  has  been  about  3  per  cent,  for  many  years.  This 
indicates  that  a  very  substantial  reduction  in  the  amount 
of  syphilis  was  effected  in  spite  of  adverse  circumstances, 
for  the  prostitutes  in  this  locality  are  almost  all  Mexican 
women  of  low  intelligence  and  are  almost  all  infected  with 
syphilis.  (A  Wassermann  made  at  Vera  Cruz  of  10  prosti- 
tutes gave  a  positive  result  in  9.)  These  results  are  sub- 
stantially better  than  the  average  obtained  in  the  army 
generally. 

The  best  figures  that  I  have  ever  seen,  and  which  conclu- 
sively prove  the  value  of  the  prophylactic  properly  admin- 
istered, are  those  very  kindly  sent  me  by  Colonel  Edwin  P. 
Wolfe,  Medical  Corps,  from  Fort  McKinley,  P.  I.     Colonel 


190 


PERSONAL  PROPHYLAXIS 


Wolfe  was  surgeon  during  the  period  covered  and  personally 
supervised  this  work.  The  results  obtained  in  the  reduction 
of  gonorrhea  and  chancroid  were  quite  as  striking  and  remark- 
able as  the  statistics  submitted  on  syphilis,  but  are  omitted 
as  not  bearing  on  the  prevention  of  syphilis. 


Mean 
enlisted 
strength. 

Prophylactic. 

Failures  in  all 
diseases. 

Primary  syphilis. 

Treat- 
ments 
given. 

Men 
treated. 

Apparent 

failures 

in  all 

diseases. 

Per  cent, 
apparent 
failures. 

Men  who 
took 
treat- 
ment. 

Men  who 
did  not 
receive 
prophy- 
lactic. 

1913: 
Jan. 
Feb. 
Mar. 
Apr. 
May 
June 
July 
Aug. 
Sept. 
Oct. 
Nov. 
Dec. 

3609 
1568 
2413 
3216 
2910 
1951 
1982 
2505 
2492 
2700 
2543 
3018 

761 
506 
501 
568 
662 
356 
389 
472 
452 
498 
671 
949 

562 
492 
378 
432 
508 
275 
331 
382 
372 
376 
462 
533 

2 
2 
2 
3 
2 
2 
3 
4 
0 
1 
0 
0 

0.26 

0.39 

0.4 

0.52 

0.3 

0.56 

0.77 

0.84 

0 
0.2 

0 

0 

1 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

,    9 
3 

5      , 
3 

2 
7 
2 
2 
1 
3 
1 
4 

Total 

6785 

21 

1 

42 

1914: 
Jan. 
Feb. 
Mar. 
Apr. 
May 
June 
July 
Aug. 
Sept. 
Oct. 
Nov. 
Dec. 

2165 
1664 
3089 
3026 
3232 
3042 
2844 
2591 
1954 
1883 
2487 
2686 

724 
619 
988 
861 
870 
818 
690 
840 
701 
603 
799 
774 

563 
500 
677 
627 
630 
615 
538 
666 
565 
446 
590 
606 

0 
0 
2 
1 
3 
3 
5 
6 
1 
2 
0 
5 

0 

0 
0.2 
0.11 
0.34 
0.36 
0.73 
0.7 
0.001 
0.33 

0 
0.64 

0 
0 
0 

1 

0 
0 
0 
0 
0 
0 
0 
0 

3 

1 
6 
5 
3 
1 
2 
2 
2 
1 
1 
4 

Total 

9287 

28 

1 

31 

1915: 

May 
June 
July 
Aug. 

3080 
2998 

2982 
2780 

896 
802 
805 
890 

749 
652 
692 

722 

7 
8 
5 
4 

0 
0 
0 
0 

14 
4 
3 
5 

Total 

3393 

24 

0 

26 

METHODS  TO  PREVENT  GENITAL  INFECTION     191 

We  may  conclude  that  the  experimental  work  on  the  pre- 
vention of  syphiHs  and  long  experience  with  the  practical 
use  of  a  prophylactic  have  given  substantially  concordant 
results,  namely,  that  s}'philis  undoubtedly  can  be  prevented 
by  the  use  of  various  prophylactics,  and  particularly  by  the 
use  of  33  per  cent,  calomel  ointment.  In  practice  it  cannot 
be  expected  that  the  use  of  the  prophylactic  will  be  invari- 
ably successful,  but  it  seems  reasonable  to  believe  that  if 
properly  applied  during  the  first  hour  after  exposure  it  will 
prevent  the  great  majority  of  syphilitic  infections.  The 
efficacy  of  the  prophylactic  diminishes  rapidly  as  the  time 
between  its  use  and  the  exposure  increases.  In  addition  to 
this  time  factor  there  will  be  variations  in  efficacy  in  practice, 
depending  upon  the  care  with  which  the  calomel  ointment  is 
compounded  and  upon  the  intelligence  and  thoroughness 
with  which  the  prophylactic  is  applied. 

When  dealing  with  large  bodies  of  men  experience  has 
shown  that  good  results  can  only  be  expected  from  the  use 
of  the  prophylactic  when  medical  and  other  authorities 
unite  to  instruct  the  men  in  its  value  and  in  the  method  of 
use.  Finally,  the  prophylactic  must  be  provided  and  its 
use  made  compulsory  by  the  imposition  of  various  penalties 
in  case  of  neglect  to  use  the  prophylactic  after  exposure. 
And  in  order  to  enforce  this  regulation,  frequent  venereal 
inspections  are  necessary  to  prevent  the  concealment  of 
disease  on  the  part  of  those  men  who  wish  to  avoid  the 
penalties. 

It  is  quite  possible  to  adopt  such  measures  in  the  military 
services,  though  it  has  been  abundantly  shown  that  the 
success  of  such  measures  depends  upon  the  interest  and  con- 
tinued vigilance  of  both  the  medical  officer  and  the  com- 
manding officer,  and  the  work  must  be  continued  because 
experience  has  shown  that  it  may  be  successful,  and  that 
every  means  available  must  be  used  to  reduce  the  prevalence 
of  venereal  diseases.  It  seems  evident  that  we  cannot  antici- 
pate very  satisfactory^  results  from  the  introduction  of  pro- 
phylactic methods  among  bodies  of  men  not  under  strict 
discipline,  military  or  otherwise,  although  the  very  best 
results  may  be  anticipated  from  the  use  of  the  prophylactic 


192  PERSONAL  PROPHYLAXIS 

by  intelligent  and  instructed  individuals.  Under  these  cir- 
cumstances each  civil  sanitary  officer  must  decide  for  himself 
to  what  extent  he  will  make  use  of  prophylactic  methods 
after  taking  into  consideration  all  the  local  conditions. 

As  there  have  been  so  many  variations  in  the  method  of 
using  a  prophylactic,  it  appears  that  it  will  be  of  some 
service  to  outline  a  satisfactory  method. 

Before  intercourse  use  a  liberal  amount  of  vaselin  or  other 
lubricant.  This  aids  in  preventing  abrasions  and  forms  a 
coating  through  which  infectious  organisms  can  only  pene- 
trate with  difficulty.    As  soon  as  possible  after  intercourse : 

1.  Wash  the  genitalia  thoroughly  with  soap  and  water, 
using  plenty  of  soap.  Reasoner^^  has  found  that  soap  solu- 
tion kills  Treponema  pallidum  very  promptly,  and  there  is 
good  evidence  that  chancroidal  infection  may  also  be  avoided 
very  largely  by  a  thorough  cleansing  with  soap  and  water. 

2.  When  the  prophylaxis  is  performed  under  medical 
instruction  or  by  a  man  of  sufficient  intelligence  this  may 
be  followed  by  a  wash  of  1  to  1000  mercuric  chloride.  The 
efficacy  of  this  solution  is  undoubted,  but  it  should  not  be 
used  by  ignorant  persons,  nor  should  bichloride  of  mercury 
tablets  be  issued  as  a  routine. 

3.  Dry,  and  apply  about  1  dram  of  33  per  cent,  calomel 
ointment  in  lanolin.  Anhydrous  lanolin  should  not  be  used 
and  the  ointment  should  be  most  thoroughly  mixed.  This 
should  be  well  rubbed  in,  paying  particular  attention  to  the 
glans,  corona  and  prepuce,  but  neglecting  no  part  of  the 
penis  and  the  anterior  portion  of  the  scrotum.  This  should 
be  rubbed  in  for  at  least  ten  minutes,  and  should  not  be 
removed  but  should  be  allowed  to  remain  for  twelve  hours, 
meanwhile  protecting  the  clothes  by  the  application  of  an 
impervious  paper  napkin.  This  favors  absorption  and 
ensured  prolonged  action  of  the  mercury  on  any  organisms 
that  may  remain. 

4.  For  the  prevention  of  gonorrhea  a  suitable  solution  of 
some  silver  salt  may  be  instilled  into  the  urethra. 

The  Ethics  of  Venereal  Prophylaxis. — It  may  be  expected 
that  there  will  be  differences  of  opinion  concerning  the  moral- 
ity of  venereal  prophylaxis.     The  attitude  taken  toward 


METHODS  TO  PREVENT  GENITAL  INFECTION     193 

this  question  by  any  individual  will  be  based  quite  as  much 
upon  his  feelings  and  training  as  upon  cold  reason,  for  there 
is  no  fixed  standard  of  morality  to  which  all  such  questions 
may  be  made  to  conform.  It  need  cause  no  surprise  therefore 
that  equally  intelligent  and  well-meaning  people  have  taken 
sides  on  the  question  of  the  morality  of  venereal  prophylaxis. 
Each  sanitarian  must  settle  for  himself  both  the  morality 
and  expediency  of  using  prophylactic  methods  to  prevent 
venereal  diseases,  and  all  that  can  be  done  here  is  to  give 
certain  reasons  for  believing  that  such  efforts  are  not  immoral. 

The  main  objections  to  such  prophylaxis  are  based  on  two 
beliefs  that  are  very  generally  held,  namely,  that  venereal 
diseases  are  a  punishment  for  immorality,  and  that  the  fear 
of  venereal  disease  deters  many  from  vice,  so  that  by  removing 
this  fear  we  actually  encourage  vice. 

Venereal  diseases  are  not  a  punishment  for  immorality. 
The  prime  essential  of  a  punishment  is  that  it  should  be 
justly  applied;  that  is,  the  person  who  errs  should  always  be 
punished,  the  person  who  does  not  err  should  not  be  punished, 
and  the  severity  of  the  punishment  should  be  proportionate 
to  the  heinousness  of  the  offence.  Venereal  diseases  do  not 
fulfil  any  of  these  requirements  of  a  just  punishment.  Of  the 
•  many  who  indulge  in  illicit  intercourse,  some  are  infected  and 
some  are  not,  and  many  innocent  wives  and  children  are  also 
infected.  The  man  who  betrays  an  innocent  girl  escapes  all 
infection  for  the  very  reason  that  she  is  innocent,  and  yet  his 
offence  is  far  more  flagrant  than  that  of  the  man  who  consorts 
with  a  prostitute  and  becomes  infected.  Moreover,  one  man 
contracts  syphilis  and  another  gonorrhea,  thus  providing 
different  grades  of  punishment  for  the  same  offence.  One 
man  who  contracts  syphilis  perhaps  at  his  first  offence  may 
develop  paresis  or  locomotor  ataxia,  while  the  syphilis  ac- 
quired by  the  m^an  who  is  habitually  immoral  may  cause  him 
little  inconvenience.  We  must  believe  that  God  is  just,  and 
it  is  difficult  to  believe  that  a  just  God  ever  devised  such  an 
unjust  punishment.  The  belief  that  disease  is  a  punishment 
for  sin  is  an  obsolete  theology.  No  one  would  now  consider 
typhoid  fever  or  f urunculosis  a  punishment  for  sin  whatever 
may  have  been  thought  in  -lob's  time.  Disease  is  the  result 
13 


194  PERSONAL  PROPHYLAXIS 

of  our  own  ignorance  and  carelessness,  and  venereal  diseases 
are  no  exception  to  the  rule. 

The  idea  that  the  fear  of  venereal  disease  acts  as  a  deterrent 
to  immorality  is  a  very  widespread  delusion.  Fear  is  a  very 
poor  deterrent  under  any  circumstances.  At  one  time 
poisoners  were  boiled  alive,  but  this  cruel  and  unusual 
punishment  did  not  put  an  end  to  poisoning,  which  was  a  more 
popular  form  of  murder  then  than  it  has  ever  been  since. 
Our  treatment  of  criminals  has  been  based  on  the  belief  that 
fear  of  punishment  would  prevent  crime,  but  modern  penolo- 
gists are  telling  us  that  this  is  a  mistake  and  that  we  must 
reorganize  our  penitentiaries,  substituting  education  and 
moral  encouragement  for  fear.  The  fear  of  hell  did  not  make 
men  moral  even  in  the  not  very  remote  past,  when  the  belief 
in  a  real  physical  hell  was  very  vivid.  If  the  fear  of  hell  itself 
had  so  little  deterrent  effect,  how  can  we  suppose  that  the 
distant  prospect  of  a  possible  venereal  infection  would  act 
as  an  effective  deterrent? 

Moreover,  this  supposed  fear  of  venereal  diseases  is  to  all 
intents  and  purposes  non-existent.  Young  men  who  are  the 
chief  sufferers  from  venereal  diseases  feel  little  fear  of  them 
because  it  is  one  of  the  characteristics  of  youth  to  fear 
nothing.  Those  who  know  young  men  or  have  not  forgotten 
how  they  felt  when  they  were  twenty  years  of  age  will  need 
no  further  argument  on  this  point.  It  has  been  assumed 
that  this  lack  of  fear  of  venereal  diseases  on  the  part  of  young 
men  was  due  to  ignorance.  This  is  believed  to  be  an  error. 
It  is  true  that  most  young  men  are  not  well  informed  as  to  the 
nature  and  ultimate  consequences  of  venereal  diseases,  but 
all  young  men  know  that  such  diseases  exist,  and  imagination 
often  makes  the  unknown  more  terrifying  than  the  known. 
Medical  students  who  are  well  informed  on  the  subject  are 
no  more  moral  than  other  parts  of  the  student  body.  But, 
it  will  be  objected,  this  is  all  theoretical.  It  will  be  well 
therefore  to  cite  facts  indicating  the  indifference  to  fear  of 
venereal  infection.  I  have  known  many  cases  in  which  for 
various  reasons  men  have  consorted  with  women  whom  they 
knew  were  infected.  In  one  post  where  the  duty  was  very 
severe  and  where  it  was  the  custom  to  admit  all  cases  of 


METHODS   TO   PREVENT  GENITAL   INFECTION     195 

venereal  disease  to  the  hospital  a  number  of  the  men  deliber- 
ately exposed  themselves  to  women  who  were  known  to  have 
infected  other  men,  in  order  that  they  might  contract  gon- 
orrhea and  be  placed  in  hospital,  thereby  escaping  disa- 
greeable duties.  In  another  case  infected  prostitutes  were 
detained  for  treatment  in  a  certain  building.  These  women 
subsequently  complained  that  certain  men  had  gained 
access  to  this  building  and  had  had  intercourse  with  them. 
The  reason  the  men  committed  this  offence  with  women 
known  to  be  infected  and  the  reason  the  women  complained 
was  the  same,  namely,  the  men  had  not  paid. 

While  such  instances  may  be  held  to  be  unusual  and  to 
pertain  only  to  the  baser  types  of  men,  they  speak  volumes 
for  the  contempt  in  which  the  fear  of  venereal  infection  is 
held  by  many  men. 

Furthermore,  many  men  who  are  not  so  debased  continue 
to  expose  themselves  after  they  have  actually  suffered  one 
venereal  infection,  and  this  constitutes  strong  evidence  that 
fear  of  infection  does  not  act  as  a  sufficient  deterrent  to 
immorality.  Brandweiner*^  states  what  is  common  knowl- 
edge among  practitioners,  that  it  is  very  frequent  to  observe 
several  venereal  diseases  in  one  person,  and  it  is  not  to  be 
supposed  that  they  were  all  acquired  at  one  exposure.  Of 
905  patients  combined  diseases  were  present  as  follows: 

Soft  chancre  and  gonorrhea 166  times 

Soft  chancre  and  syphilis '.  158      " 

Gonorrhea  and  syphilis 894      " 

Chancroid,  gonorrhea  and  syphilis 87      " 

Vedder^''  found  that  out  of  531  Porto  Rican  soldiers 
examined  the  following  men  had  had  several  venereal 
infections: 

Syphilis  and  chancroids 26,  or  4.8    percent. 

Syphilis  and  gonorrhea 27,  or  5.0  " 

Chancroids  and  gonorrhea 39,  or  7.34  " 

Syphilis,  chancroids  and  gonorrhea   .      .      .  12,  or  2.26  " 

If  SO  many  men  continue  their  immoral  relations  although 
actually  suffering  from  venereal  disease,  and  persist  although 
infected  again  and  again,  why  should  we  suppose  that  fear 


196  PERSONAL  PROPHYLAXIS 

of  infection  will  prevent  immorality?  Personally,  I  conclude 
that  fear  of  infection  is  practically  non-existent,  and  that 
even  when  it  does  exist  it  is  a  very  feeble  deterrent  as  compared 
with  the  imperious  instinct  upon  which  the  perpetuation  of 
the  race  is  based. 

If  fear  of  venereal  disease  is  so  impotent  to  prevent  im- 
morality we  need  not  suppose  that  the  introduction  of  a 
venereal  prophylaxis  will  encourage  vice  by  removing  this 
fear.  Furthermore,  there  is  no  occasion  for  removing  any 
fear  that  may  actually  exist,  for  as  we  have  already  seen  we 
cannot  guarantee  that  the  prophylactic  measures  will  invari- 
ably succeed  in  preventing  infection.  So  much  for  the  nega- 
tive side  of  the  argument. 

On  the  positive  side,  we  may  affirm  that  it  is  a  duty  and  the 
highest  morality  to  endeavor  to  preserve  our  bodies  in  health. 
Obviously  the  individual  should  protect  himself  from  venereal 
diseases  by  living  a  moral  life.  But  suppose  he  has  committed 
a  fault  and  exposed  himself.  If  he  does  not  endeavor  to 
prevent  infection  by  using  a  prophylactic  of  known  efficacy 
he  commits  a  second  fault  of  omission,  and  two  wrongs  never 
yet  made  a  right. 

However,  we  still  have  to  face  the  problem  of  expediency. 
In  the  military  services,  prophylaxis  is  most  efficient.  The 
medical  officer  who  insists  upon  prophylaxis  does  not  encour- 
age immorality,  but,  on  the  contrary,  he  should  do  and  usually 
does  everything  in  his  power  to  discourage  it.  But  knowing 
that  in  spite  of  any  efforts  he  may  make  in  this  direction,  a 
certain  percentage  of  the  men  will  persist  in  immorality,  he 
would  be  derelict  in  his  duty  to  the  man  and  to  the  govern- 
ment if  he  did  not  endeavor  to  prevent  infection. 

The  question  is  somewhat  more  complicated  in  civil  life 
where  men  are  under  no  authority  or  discipline.  Snow's  con- 
clusions on  the  matter^"  are  as  follows:  "Such  prophylactic 
measures  can  succeed  in  only  a  percentage  of  those  cases  in 
which  adequate  instructions  have  been  given,  and  the  indi- 
vidual has  the  intelligence  to  apply  properly  the  prophylactic 
immediately  or  within  a  few  hours  of  exposure.  Obviously 
these  requirements  are  not  likely  to  be  met  by  the  immature 
boys,    the    drink-befuddled    men,    the    defective   girls,    the 


METHODS  TO  PREVENT  EXTRAGENITAL  INFECTION    197 

average  prostitutes  who  constitute  the  bulk  of  the  citizens 
who  might  be  protected  by  this  method.  It  seems  apparent 
that  prophylaxis  can  wisely  be  made  use  of  only  under  the 
advice  of  physicians  who  are  fully  informed  of  the  circum- 
stances of  each  case  and  have  an  opportunity  to  observe  each 
individual  until  the  danger  of  infection  is  passed.  It  therefore 
becomes  undesirable  to  advocate  publicly  such  measm-es  for 
individuals  without  such  supervision. " 

It  is  certain  that  venereal  prophylaxis  cannot  be  applied 
in  civil  life  with  the  same  prospect  of  success  as  in  the  army 
for  obvious  reasons.  But  inasmuch  as  a  certain  number  of 
infections  might  be  prevented  it  seems  as  though  the  above 
conclusions  were  somewhat  pessimistic  and  that  the  use  of  the 
prophylactic  should  be  encouraged.  Even  if  no  more  is  to  be 
done  in  this  direction  than  advocated  by  Snow  it  would  seem 
that  this  effort  should  at  least  be  systematized.  At  present 
there  is  no  way  in  which  physicians  in  civil  life  can  obtain 
information  on  the  subject  for  dissemination  to  patients,  nor 
can  they  be  assured  of  obtaining  a  reliable  supply  of  calomel 
ointment,  and,  as  we  have  seen,  the  success  of  prophylaxis 
depends  greatly  upon  the  percentage  of  calomel  in  the  ointment 
and  the  care  with  which  it  has  been  compounded.  It  would 
seem  that  the  health  officers  of  various  cities  might  obtain 
a  supply  of  satisfactory  prophylactic  packets  for  issue  to 
physicians,  at  the  same  time  sending  a  circular  for  the  patients 
explaining  the  method  of  use  and  what  results  might  be 
expected  from  their  use.  Physicians  could  then  distribute 
these  packets  to  such  of  theu-  patients  as  experience  has 
demonstrated  are  likely  to  need  them.  Sanitary  officers  will 
naturally  have  to  decide  for  themselves  to  what  extent  they 
wish  to  go  in  this  matter,  and  this  chapter  has  been  written 
with  a  view  of  presenting  the  facts  on  which  such  a  decision 
can  be  based. 

II.    METHODS    THAT    MAY    BE    TAKEN    BY    THE    INDI- 
VIDUAL TO  PREVENT  EXTRAGENITAL  INFECTION. 

As  pointed  out  in  the  previous  chapter,  although  accidental 
extragenital  infections  have  been  acquired  in  every  conceivable 


198  PERSONAL  PROPHYLAXIS 

way,  yet  the  great  majority  of  these  infections  have  been 
acquired  as  the  result  of  a  small  number  of  insanitary  prac- 
tices, most  of  which  can  be  controlled  or  entirely  prevented 
by  the  individual. 

Buccal  infections  were  found  to  be  the  most  numerous  of 
all  extragenital  infections,  constituting  about  43  per  cent, 
of  all  extragenital  infections,  while  nearly  60  per  cent,  of  these 
buccal  infections  are  caused  by  promiscuous  kissing. 

Kissing. — This  is  a  subject  that  is  difficult  for  a  person  with 
a  sense  of  humor  to  treat  seriously,  and  yet  it  must  be  seriously 
considered  as  the  most  important  single  method  by  which 
accidental  syphilitic  infection  is  transmitted.  No  sanitarian 
outside  of  the  comic  paper  expects  to  prohibit  legitimate 
kissing,  and  yet  it  is  certain  that  the  general  public  must  be 
educated  to  stop  promiscuous  kissing.  The  male  mind  can 
scarcely  understand  why  certain  women  insist  on  kissing 
every  woman  and  child  that  they  meet.  Parents  should 
insist  that  their  children  be  not  kissed  by  stray  callers,  and 
particularly  not  by  servants  and  nursemaids  who  are  fre- 
quently of  loose  morals  and  who  may  become  infected  at  any 
time  even  though  not  sj^hilitic  when  employed.  When  the 
public  understands  that  not  only  syphilis,  but  also  pneu- 
monia, influenza,  the  common  cold  and  other  diseases  may 
be  transmitted  through  kissing,  the  practice  will  become 
automatically  reduced  to  normal  and  proper  limits. 

Instruments  Used  in  Various  Trades. — Many  cases  of  acci- 
dental infection  have  been  transmitted  as  the  result  of  the 
common  use  of  various  instruments,  such  as  blow-pipes  and 
pipettes.  So  far  as  possible  in  these  trades  all  workmen 
should  have  their  own  instruments,  and  the  use  of  such 
instruments  in  common  should  be  prohibited. 

Smokers'  Articles. — ^Many  cases  are  on  record  in  which  the 
victim  was  infected  after  using  a  pipe  or  smoking  cigars  or 
cigarettes  previously  used  by  a  syphilitic.  It  can  hardly 
be  supposed  that  persons  of  this  caliber  can  be  reached  by 
the  processes  of  education,  but  an  attempt  may  be  made 
whenever  possible. 

Drinking  Glasses. — The  comm^on  drinking  glass  has  also 
been  responsible  for  many  infections.    However,  it  is  hardly 


METHODS  TO  PREVENT  EXTRAGENITAL  INFECTION    199 

necessary  to  make  recommendations  on  this  subject  at  the 
present  day  of  bubbhng  fountains,  paper  drinking  cups  and 
individual  communion  cups.  Every  sanitary  officer  should 
be  on  guard  to  eliminate  the  common  drinking  glass  at 
schools  and  other  institutions  under  his  control,  and  the  use 
of  paper  cups  at  soda-water  fountains  and  other  public 
drinking  places  should  be  enforced  whenever  possible.  While 
these  are  properly  public  health  measures  when  taken  by 
the  sanitary  officer,  yet  every  individual  can  protect  himself 
by  refusing  to  use  a  common  cup.  A  good  rule  f6r  the  indi- 
vidual is  to  put  nothing  in  the  mouth  that  has  been  in  the 
mouth  of  another  person.  The  general  adoption  of  this  rule 
would  practically  eliminate  buccal  syphilitic  infection  by 
intermediate  objects.  The  same  rule  should  be  enforced, 
so  far  as  possible,  in  the  case  of  children.  Children  have 
been  infected  by  a  syphilitic  nurse  who  tested  their  food 
with  the  same  spoon  used  by  the  children.  No  eating 
utensils  should  be  used  by  more   than  one  person  until 

cleansed. 

Minor  Operations.— Another  important  group  of  infections 
are  those  caused  by  minor  operations,  mostly  by  ignorant 
persons,  though  the  skirts  of  the  medical  profession  are  not 
entirely  clean  in  this  matter.  The  great  number  of  infec- 
tions that  have  been  transmitted  through  the  practice  of 
vaccination  constitutes  a  serious  reproach  and  one  that  has 
undoubtedly  furnished  a  basis  for  some  of  the  antiyaccina- 
tionist  charges.  Whenever  any  serious  objection  is  made 
against  our  customs  or  methods  on  the  part  of  the  laity  it  is 
well  to  investigate  the  matter  with  an  open  mind.  Home- 
opathy would  have  died  at  birth  had  it  not  been  for  the 
practice  of  many  of  the  profession  at  that  day  of  bleeding 
and  purging  their  patients  to  death.  Christian  Science 
would  not  flourish  today  were  it  not  for  the  fact  that  no 
patient  can  gain  a  respectful  hearing  who  cannot  furnish  some 
objective  signs  that  we  can  detect  by  our  present  admittedly 
imperfect  methods  of  physical  examination.  That  syphilis 
is  transmitted  today  by  vaccination  in  any  sufficient  number 
of  cases  to  warrant  any  sanitary  action  I  do  not  believe, 
although  a  suit  for  malpractice  would  appear  justifiable.    In 


200  PERSONAL  PROPHYLAXIS 

this  case,  as  in  the  case  of  homeopathy,  we  are  suffering  for 
the  sins  of  our  predecessors.  Every  physician  who  is  required 
to  perform  vaccination  en  masse  should  be  on  guard  in  this 
matter.  In  this  day  of  bovine  lymph  the  accident  can  only 
occur  through  using  the  same  knife  or  other  instrument  for 
scarification  on  numbers  of  people.  For  this  reason,  when 
vaccinating  a  number  of  people,  care  should  be  exercised, 
and  the  same  knife  or  scarificator  should  not  be  used  on 
more  than  one  person  without  sterilization. 

Circumcision. — Circumcision  performed  as  a  rite  at  birth 
has  been  responsible  for  many  infections.  Among  intelligent 
Jews  this  operation  is  today  performed  in  accordance  with 
accepted  surgical  technic,  and  it  is  only  among  the  ignorant, 
whom  it  is  most  difficult  to  reach,  that  the  danger  of  infec- 
tion exists.  Personal  prophylaxis  may  be  secured  to  some 
extent  by  education  of  these  people  in  the  use  of  better 
methods,  and  for  the  rest  the  sanitary  officer  may  endeavor 
to  insist  upon  the  use  of  aseptic  methods  on  the  part  of  those 
persons  performing  this  operation.  Infection  has  been 
transmitted  by  barbers  with  sufficient  frequency  to  merit 
attention.  This  has  usually  followed  from  the  treatment 
of  a  cut  by  a  syphilitic  barber,  who  either  touched  the  cut 
with  a  caustic  stick  wet  with  his  own  saliva  or  applied  a 
piece  of  plaster  wet  with  his  own  saliva.  Such  infections 
may  be  avoided  by  observance  of  the  following  rule:  permit 
no  person  to  apply  to  any  injury  any  plaster  or  object  that 
is  moistened  with  saliva.  The  sanitary  regulation  of  barbers 
and  barber  shops  is  generally  undertaken  by  most  municipal 
health  departments  and  need  not  be  discussed  in  this  place. 

Tattooing. — A  certain  number  of  infections  have  been 
transmitted  by  tattooing  when  the  operator  used  his  own 
saliva  for  mixing  the  pigment  or  wetting  the  needles.  It 
should  be  sufficient  to  point  out  that  any  individual  who 
wishes  to  supplement  the  art  galleries  on  his  person  should 
insist  that  the  operator  use  sanitary  methods  and  does  not 
use  his  own  saliva  in  the  process.  These  operators  should 
also  be  licensed  and  subject  to  public  health  regulation. 

Physicians,  Nurses,  and  Those  in  Attendance  on  the  Sick. — 
The  number  of  syphilitic  infections  transmitted  to  physicians 


METHODS  TO  PREVENT  EXTRAGENITAL  INFECTION   201 

and  those  in  attendance  on  the  sick  are  so  numerous  that 
the  disease  may  be  well  called  an  occupational  disease  of 
physicians.  Obstetricians  are  now  insisting  on  the  use  of 
the  gloved  hand  in  making  vaginal  examinations  of  women 
in  labor  in  order  to  avoid  infection  of  the  woman,  but  the 
measure  is  equally  important  to  prevent  syphilitic  infection 
of  the  physician.  No  vaginal  or  rectal  examination  should 
be  made  except  with  the  gloved  hand.  The  physician  should 
endeavor  at  all  times  to  keep  the  skin  of  his  hands  intact, 
but  small  abrasions  and  hangnails  are  so  common  that 
gloves  should  be  used  as  an  additional  protection  much  more 
frequently  than  is  the  case  at  present.  Fortunately,  the  sur- 
geon is  now  protected,  owing  to  the  almost  universal  use  of 
rubber  gloves  in  operating,  but  I  have  seen  many  physicians 
palpate  a  suspected  chancre  with  the  ungloved  hand  to  detect 
induration.  Nurses  should  be  instructed  as  to  the  danger 
of  acquiring  infection  in  such  operations  as  catheterizing 
female  patients,  and  should  also  wear  rubber  gloves  when 
performing  such  services.  In  case  the  patient  is  known  to 
be  syphilitic  the  nurse  should  be  informed  of  the  fact,  and 
the  physician  should  give  explicit  instructions  enabling  her 
to  avoid  infection.  Mid  wives  should  be  taught  to  use  rubber 
gloves  for  their  own  protection  as  well  as  that  of  the  patient. 
While  dentists  can  probably  not  wear  rubber  gloves,  they 
should  be  thoroughly  familiar  with  the  appearance  of  the 
mucous  patch,  and  should  use  the  utmost  caution  in  operating 
on  their  syphilitic  patients  to  avoid  abrasions  of  the  skin. 
Hangnails  or  existing  abrasions  should  be  covered  with 
collodion.  It  is  taken  for  granted  that  all  dental  instruments 
are  always  sterilized  subsequent  to  one  operation  and  before 
operating  on  a  new  patient.  It  should  not  be  necessary  to 
^  make  rules  for  the  medical  profession,  but  having  recognized 
the  frequency  of  accidental  infection,  every  physician 
should  be  able  to  make  his  own  rules  for  the  avoidance  of 
this  infection.  The  habitual  use  of  the  rubber  glove  whenever 
the  hand  or  fingers  are  brought  in  contact  with  mucous 
surfaces  will  avoid  the  majority  of  infections. 

Wet-nurses. — In  the  past  many  infections  have  been  trans- 
mitted both  from  the  nurse   to    the  child  and  vice  versa: 


202  PERSONAL  PROPHYLAXIS 

Since  methods  of  artificial  feeding  have  been  improved  the 
employment  of  wet-nm-ses  has  fallen  off,  and  this  method  of 
transmission  is  not  of  great  importance  today.  Should  a 
wet-nurse  be  employed,  however,  the  danger  in  this  individual 
case  is  exactly  the  same  as  it  has  been  in  the  past.  Whoever 
employs  a  wet-nurse  should  insist  on  a  careful  medical  exami- 
nation to  detect  the  presence  of  syphilis,  including  a  Wasser- 
mann  reaction,  and  the  nurse  should  equally  insist  on  a 
similar  examination  of  the  infant  to  be  nursed,  and  also  of  the 
mother,  unless  the  physician  is  able  to  assure  her  from  his 
previously  acquired  intimate  knowledge  of  the  family  that 
syphilis  does  not  exist. 

SYPHIUS  AND  MARRIAGE. 

It  is  impossible  to  prevent  the  marriage  of  syphilitics  by 
law,  although  legislation  making  syphilis  a  bar  to  marriage 
has  been  attempted  by  several  States.  According  to  Cabot^^ 
"Nine  States,  namely,  Indiana,  Michigan,  North  Dakota, 
Oregon,  Pennsylvania,  Utah,  Vermont,  Washington  and 
Wisconsin,  have  legislation  which  purports  to  make  syphilis 
a  bar  to  marriage;  but  in  most  of  them  the  laws  are  such  as 
to  be  largely  worthless.  Thus  the  enlightened  legislation 
of  Utah,  Washington  and  North  Dakota  prohibits  marriage 
of  persons  having  syphilis  except  where  the  female  is  over 
forty-five,  apparently  having  no  interest  at  all  in  the  lady 
after  that  period.  The  solons  of  Wisconsin  and  Oregon 
prohibit  only  the  male,  allowing  the  female  to  disseminate 
the  disease  at  will.  Utah  and  Michigan  forbid  the  marriage 
but  require  no  affidavit.  Indiana,  Pennsylvania  and  Wash- 
ington require  an  affidavit  and  thereby  put  a  premium  on 
perjury.  North  Dakota,  Oregon  and  Wisconsin  require  a 
medical  certificate  showing  freedom  from  such  disease. 
Those  States  which  forbid  the  marriage  of  the  syphilitic  but 
requhe  only  an  affidavit  or  nothing  at  all  obviously  cannot 
expect  to  diminish  the  number  of  such  individuals  who 
marry,  and  these  laws  therefore  in  practice  only  enable  the 
State  to  step  in  after  the  fact.    Such  laws,  while  perhaps  of 


SYPHILIS  AND  MARRIAGE  203 

interest  in  divorce  proceedings,  cannot  be  regarded  in  any 
sense  as  public  health  measures.  The  States  which  require 
a  medical  certificate  have  undertaken  a  much  more  preten- 
tious measure,  and  it  is  of  interest  to  look  into  the  question 
in  some  detail." 

The  Wisconsin  law  requires  that  "Such  certificates  shall 
be  made  by  a  licensed  physician,  shall  be  filed  with  the 
application  for  license  to  marry,  and  shall,  read  as  follows, 
to  wit: 

"I (name  of  physician) being  a  legally  licensed 

physician,   do   certify  that   I   have  this day   of 

19 carefully  and  thoroughly  examined  (name  of 

person) ,  having  applied  the  recognized  clinical   and 

laboratory  tests  of  scientific  search  and  find  him  to  be  free 
from  all  venereal  diseases  so  nearly  as  can  be  determined." 

It  was  provided  in  the  law  that  the  fee  for  this  examination 
should  not  exceed  $3. 

The  absurdity  of  such  a  law  is  so  self-evident  that  no  long 
discussion  of  it  is  required.  An  examination  to  exclude  the 
presence  of  venereal  disease  at  any  given  moment  is  impos- 
sible. Even  to  say  that  such  disease  is  probably  absent 
requires  a  most  intensive  examination  by  a  specially  trained 
man,  combined  with  the  results  obtained  by  various  labora- 
tory investigations.  All  of  these  findings  must  be  interpreted 
in  the  light  afforded  by  the  history,  and  may  readily  be 
worthless  if  the  patient  is  attempting  to  deceive.  Since  no 
reputable  physician  will  undertake  such  an  examination  for 
a  fee  of  $3,  the  law,  in  the  words  of  Cabot,  "gives  rise  to  a 
false  sense  of  security,  protects  the  unscrupulous,  penalizes 
the  honest,  and  deceives  the  community  in  general  by  what 
can  only  be  described  properly  as  fake  certificates." 

It  would  be  possible  to  require  by  law  a  negative  Wasser- 
mann  if  the  State  makes  suitable  provision  for  obtaining  a 
free  Wassermann  test  at  a  public  laboratory.  Such  a  test 
would,  of  course,  not  definitely  exclude  the  possibility  of 
syphilis,  and  it  would  exclude  certain  individuals  who  have 
a  positive  Wassermann,  but  who  are  incapable  in  all  prob- 
ability of  transmitting  their  infection. 


204  PERSONAL  PROPHYLAXIS 

It  is  clear  therefore  that  the  great  burden  of  responsi- 
bihty  in  regulating  the  marriage  of  syphilitics  must  be  borne 
by  the  physician  who  treats  such  cases.  Shall  he  permit  the 
marriage  of  his  syphilitic  patients,  and  if  so,  when?  Shall 
we  adopt  a  counsel  of  perfection  and  forbid  every  syphilitic 
to  marry  until  he  is  cured,  and  if  so,  what  shall  we  adopt 
as  a  standard  of  cure?  Or  shall  we  adopt  certain  rules  which 
experience  has  indicated  form  a  fairly  safe  guide? 

As  this  is  a  matter  concerning  which  there  is  much  honest 
difference  of  opinion,  it  would  be  presumptuous  for  any 
man  to  state  categorically  a  set  of  conditions  to  which  every 
syphilitic  would  have  to  conform  before  being  permitted 
to  marry.  But  it  is  quite  permissible  to  discuss  the  subject 
and  to  outline  principles  that  it  is  believed  will  afford  safe 
guidance  in  the  majority  of  cases.  In  doing  this  we  should 
duly  weigh  past  experience  together  with  our  more  recent 
knowledge  of  the  disease. 

Fournier^^  said:  "We  are  consulted  in  this  matter  solely 
as  physicians,  and  as  physicians  we  must  answer  without 
being  influenced  by  any  other  considerations  whatever. 
It  must  be  understood  in  advance  that  many  will  ignore  and 
defy  the  prohibition  and  will  marry  in  spite  of  it." 

"All  kinds  of  arguments  will  be  advanced,  such  as  an 
engagement  already  existing  and  similar  family  or  personal 
reasons.  But  the  physician  must  ignore  all  such  arguments 
and  stick  to  the  pathology  of  the  disease  as  exhibited  in  that 
particular  patient."  Fournier  thought  that,  with  a  few 
exceptions,  syphilis  constitutes  only  a  temporary  bar  to 
marriage,  after  which  period  the  patient  reverts  to  a  state 
of  health  sufficient  to  qualify  for  a  husband  and  parent. 
He  was  able  to  give  87  observations  on  syphilitics  who 
married  and  did  not  infect  their  wives  and  who  had  a  total 
of  156  infants  who  were  absolutely  healthy  (it  must  be 
remembered  that  this  was  before  the  days  of  the  Wassermann 
reaction).  As  the  result  of  his  great  experience  Fournier 
concluded,  in  1880,  that  marriage  should  be  prohibited  to 
every  man  having  syphilis  which  was  transmissible,  and  that 
it  ought  to  be  permitted  to  men  in  whom  the  disease  was  in 
such  a  condition  as  not  to  be  transmissible.    He  summarized 


SYPHILIS  AND  MARRIAGE  205 

the  general  rules  governing  the  marriage  of  syphilitics  as 
follows : 

1.  Absence  of  actual  specific  lesions. 

2.  Advanced  age  of  the  infection. 

3.  A  certain  period  of  absolute  immunity. 

4.  Non-menacing  character  of  the  disease. 

5.  Sufficient  specific  treatment. 

That  these  rules  were  considered  rather  severe  may  be 
gathered  from  the  following  remarks  of  Hutchinson"'  (page 
553)  as  late  as  1909:  "Within  the  memory  of  some  of  us 
surgical  authorities  would  sanction  marriage  after  a  brief 
treatment  and  only  a  few  weeks'  interval  from  the  disappear- 
ance of  the  secondary  symptoms.  Next  more  cautious 
counsels  prevailed,  and  a  year  was  insisted  upon,  then  two 
years,  and  finally  the  observation  of  possibilities  has  induced 
some  authorities,  chiefly  of  the  Paris  school,  to  suggest  five 
years  as  a  minimum,  and  to  prefer  even  longer  periods. 
The  question  under  discussion  at  the  present  time  is  whether 
Professor  Fournier's  dicta  do  not  take  rank  as  counsels  of 
perfection  and  whether  the  two  years'  rule,  now  generally 
acted  upon  in  British  practice,  is  not  sufficient  to  secure 
reasonable  social  safety.  It  is  to  be  understood  that  those 
who  are  content  with  this  rule  advocate  continuous  treat- 
ment with  mercury  during  the  two  years."  .  .  .  "We 
must  not  base  our  general  rules  on  this  very  important 
question  upon  exceptional  facts.  ...  It  is  to  be 
remembered  that  although,  in  fear  of  syphilis,  a  surgeon  may 
forbid  marriage  he  cannot  enforce  continence.  In  most 
cases  the  risk — often  an  imaginary  one,  or  at  most  infinitesi- 
mally  small — is  simply  shifted  from  a  wife  to  a  concubine, 
from  one  of  the  richer  classes,  it  may  be,  to  one  of  the 
poorer."  .  .  .  "Counsels  of  perfection  are  often  not 
trustworthy.  I  unhesitatingly  record  my  conviction — that 
of  an  old  man  who  has  had  much  social  experience — that, 
provided  the  two  years'  interval  be  observed,  the  dangers 
to  society  from  needlessly  prolonged  celibacy  infinitely 
exceed  the  risks  of  the  communication  of  syphilis.  .  .  . 
We  must  not  attempt  too  confidently  to  control  nature,  nor 
must  we  bring  our  imperfect  knowledge  rashly  into  predomi- 
nance in  practical  affairs." 


206  PERSONAL  PROPHYLAXIS 

Finger's  conclusions,  written  in  1896,  are  as  follows  :^^ 

1.  While  untreated  syphilis  may  lose  its  contagiousness 
and  power  of  hereditary  transmission,  yet  in  numerous  cases 
these  powers  may  be  retained  for  many  years. 

2.  Systemic  treatment  shortens  the  contagious  period  so 
that  at  the  end  of  four  or  five  years  the  danger  to  wife  and 
children  is  small  in  the  majority  of  cases. 

3.  Experience  shows,  however,  that  in  the  most  carefully 
treated  cases  a  small  fraction  may  retain  the  capability  of 
transmitting  the  infection  for  fourteen  or  fifteen  years,  or 
even  longer. 

4.  It  follows  therefore  that  no  definite  rule  can  be  deduced 
that  will  always  be  satisfactory. 

The  minimal  conditions  outlined  by  Finger  are  as  follows : 

1.  A  mild  normal  course  of  the  disease.  Severe,  visceral 
syphilis  and  malignant  syphilis  are  excluded. 

2.  An  interval  of  at  least  five  full  years  between  infection 
and  marriage. 

3.  An  interval  of  three  years  from  the  last  syphilitic  mani- 
festation to  marriage,  with  careful  observation  to  determine 
the  existence  of  slight  erosions  and  other  symptoms. 

4.  A  correspondingly  systematic  treatment  of  the  disease. 

5.  An  energetic  mercurial  treatment  just  before  the 
marriage. 

6.  It  is  the  duty  of  the  physician  to  warn  the  patient  that 
marriage  may  not  be  absolutely  safe.  That  he  must  watch 
for  small  erosions  on  the  genitalia  or  in  the  mouth  that  may 
infect  his  wife.  The  family  physician  should  know  the  facts 
so  that  he  can  watch  both  wife  and  children,  and  afford 
prompt  treatment  should  it  become  necessary. 

The  reasoning  of  Fournier  is  unassailable.  Marriage  should 
be  prohibited  to  every  man  who  may  transmit  his  infection  to 
his  wife  or  children,  and  it  should  be  permitted  to  men  who 
cannot  transmit  the  infection.  There  is  also  truth  in  Hutchin- 
son's contention  that  counsels  of  perfection  are  often  not  trust- 
worthy in  practice.  It  will  probably  not  be  possible  to  insist 
on  a  cure  in  all  cases.  The  serological  findings  undoubtedly 
afford  the  best  index  as  to  whether  a  cure  has  been  effected, 
and  it  can  hardly  be  claimed  that  a  man  having  a  positive 


SYPHILIS  AND  MARRIAGE  207 

Wassermann  reaction  is  cured  even  if  he  has  had  no  other 
cHnical  manifestations  of  the  disease  for  many  years.  The 
Wassermann  reaction  may  be  persistently  positive  in  spite  of 
efficient  treatment.  If  this  is  caused  by  an  aortitis  or  a  cord 
lesion  the  man  is  incapable  of  transmitting  his  infection, 
though  it  may  be  economically  a  poor  risk  for  him  to  assume 
the  burden  of  a  family  with  the  possibility  of  his  early  death 
from  these  conditions.  And  how  can  we  be  sure  in  any  case 
that  the  testicles  are  not  affected  and  that  the  infection  can- 
not be  transmitted  by  this  route  even  though  there  have 
been  no  external  clinical  manifestations  for  years? 

It  appears  to  the  writer  that  it  is  sufficiently  evident  that 
the  character  of  the  disease  is  such  that  it  is  impossible  to 
issue  any  guarantee  of  safety  whatever  except  in  the  presence 
of  a  definitely  established  cure.  To  such  cured  patients  we 
may  unhesitatingly  give  the  desired  permission  to  marry. 

Standard  of  Cure. — ^Almost  every  man  who  deals  with 
syphilis  has  his  own  standard  derived  from  some  authority, 
and  no  man  should  attempt  to  set  up  a  standard  of  his  own 
without  a  vast  experience.  The  army  experience  with  this 
disease  is  very  large  and  is  more  satisfactory  than  most 
private  practice  because  the  men  are  continuously  under 
observation  for  several  years.  In  1911  the  following  standard 
was  tentatively  adopted  :^^  One  year  without  treatment, 
without  any  suspicious  clinical  symptoms,  with  a  number  of 
negative  Wassermann  reactions  and  no  positive  ones.  This 
standard  was  soon  shown  to  be  insufficient,  for  it  was  found 
that  cases  could  go  for  twenty-four  months  without  symp- 
toms and  with  a  continuously  negative  Wassermann  reaction 
and  later  develop  a  positive  reaction,  while  many  cases 
negative  with  the  usual  reaction  would  give  a  positive 
provocative  Wassermann  reaction.  The  standard  was 
therefore  changed  as  follows:  One  year  without  treat- 
ment, without  any  suspicious  clinical  signs,  with  several 
negative  Wassermann  reactions  and  no  positive  ones,  and 
with  a  negative  provocative  Wassermann  reaction  and 
luetin  test  at  the  end  of  the  year.  This  standard  has  been 
used  for  about  five  years,  during  which  time  the  records  of 
about  5000  completed  cases  have  been  received.    However, 


208  PERSONAL  PROPHYLAXIS 

many  of  these  cases  were  separated  from  the  service  before 
the  period  of  observation  was  completed,  many  of  them  were 
old  intractable  cases  from  the  start,  and  in  other  cases  a 
sufficient  attempt  was  not  made  to  fulfil  the  standard  of 
cure.  However,  about  120  cases  have  fulfilled  this  standard, 
and  of  these  cases  it  may  be  said  that  in  no  case  has  there 
been  evidence  that  the  man  was  not  cured,  while  in  several 
instances  there  has  been  evidence  that  the  man  was  cured, 
as  shown  by  the  fact  that  a  new  syphilitic  infection  was 
acquired.  The  writer  believes  therefore  that  this  standard, 
while  rather  severe,  is  a  very  good  indication  of  a  real  cure. 
As  some  doubt  has  been  thrown  on  the  specificity  of  the  luetin 
reaction,  this  might  be  omitted  from  the  standard,^  and  a 
negative  examination  of  the  spinal  fluid  (cells,  colloidal  gold, 
globulin  and  Wassermann  reaction)  should  be  added,  as 
experience  has  shown  that  positive  results  are  obtained  not 
infrequently  from  such  examination  of  the  spinal  fluid  even 
when  all  other  tests  are  negative. 

If  our  army  experience  is  any  indication  of  conditions  in 
civil  practice  it  seems  probable  that  very  few  men  will  be 
able  to  fulfil  these  conditions.  The  difficulty  in  securing  cures 
is  due  not  only  to  the  difficulty  in  curing  the  disease,  which 
is  admittedly  great,  but  even  more  to  the  peripatetic  habit  of 
the  average  patient  with  venereal  disease,  which  renders  it 
impossible  for  the  physician  to  follow  the  patient  long 
enough  to  fulfil  the  conditions.  This  matter  should  be 
impressed  upon  the  victim  of  syphilis  at  his  very  first  visit. 
Most  men  expect  to  marry  at  some  time  in  the  future,  and 
if  the  necessity  of  complying  with  such  a  standard  before 
marriage  is  impressed  on  the  patient,  some  at  least  may  be 
able  and  willing  to  comply.  The  cost  of  the  Wassermann 
examinations  in  cases  so  followed  is  considerable,  and  State 
and  city  boards  of  health  can  perform  a  most  admirable 
service  to  the  community  by  following  these  treated  cases 
free  of  charge. 

In  regard  to  the  men  who  cannot  comply  with  a  standard  of 
cure  it  is  the  opinion  of  the  writer  that  the  physician  must  use 
his  best  judgment  applied  to  the  facts  of  the  individual  case. 
Permission  to  marry  should  be  withheld  until  the  man  fulfils 


SYPHILIS  AND  MARRIAGE  209 

certain  conditions,  and  should  only  then  be  given  accom- 
panied by  a  warning  that  the  marriage  may  not  be  absolutely 
safe.  The  rules  formulated  by  Finger  and  already  quoted 
seem  excellent,  except  that  the  use  of  salvarsan  and  a 
negative  Wassermann  are  not  required  by  Finger.  As  thus 
modified  these  rules  would  be  as  follows: 

1.  A  mild  normal  coiu'se  of  the  disease. 

2.  An  efficient  course  of  treatment  with  both  salvarsan 
and  mercury  in  accordance  with  the  best  practice  in  the 
treatment  of  syphilis. 

3.  An  interval  of  at  least  four  full  years  between  infection 
and  marriage. 

4.  An  interval  of  three  years  from  the  last  syphilitic  mani- 
festation to  marriage,  with  careful  observation  to  determine 
the  existence  of  symptoms. 

5.  A  negative  Wassermann  reaction  just  before  marriage, 
best  confirmed  by  a  test  at  a  second  laboratory  to  ensure 
accuracy. 

Wassermann-fast  Cases. — If  these  cases  comply  with  the 
other  conditions  just  mentioned  it  is  very  probable  that  they 
might  not  infect  either  wife  or  children.  In  such  cases  the 
physician  might  reasonably  take  the  position  of  advising 
against  marriage,  though  not  absolutely  prohibiting  it,  point- 
ing out  to  the  patient  the  possible  danger  of  aneurysm  and 
cerebrospinal  syphilis  in  later  life.  A  most  careful  physical 
examination  would  be  made  to  determine,  if  possible,  the 
location  and  nature  of  the  active  focus  of  the  disease  giving 
rise  to  the  positive  Wassermann.  Further,  it  can  only  be 
said  that  this  examination  and  diagnosis,  and  the  stating  of 
the  case  to  the  patient  in  such  terms  that  he  can  form  an 
intelligent  opinion  of  his  own  situation,  and  yet  in  such 
terms  that  he  will  not  lose  all  hope  and  meditate  suicide,  will 
tax  all  the  skill,  ingenuity  and  judgment  of  the  physician. 

REFERENCES. 

1.  Marschalko:  Reflexionen  iiber  die  Prophylaxe  der  Venerischen 
Erkrankungen ,  Mlinchen.  med.  Wchnschr.,  1901,  xlviii,  827. 

2.  Hutchinson,  Jonathan:     SyphiHs,   1909,  Cassell  &  Co.,  p.   16. 

3.  Freeland:  Circumcision  as  a  Preventive  of  Syphilis  and  Other 
Disorders,  Lancet,  1900,  ii,  1869. 

14 


210  PERSONAL  PROPHYLAXIS 

4.  Moyer:     Circumcision  in  Restricting  the  Spread  of   Syphilis,    Jour. 
Am.  Med.  Assn.,  1901,  xxxvi,  886. 

5.  Hutchinson,    J.:     Two    Clinical    Lectures    on    Primary    Syphilitic 
Chancres,  Lancet,  1900,  i,  1575. 

6.  Breitenstein :     Die    Circumcision    in    der    Prophylaxis    der    Syphilis, 
Dermat.  CentralbL,  1902-1903,  vi,  34. 

7.  Le  Pileur:     Les  Preservatifs  de  la  Syphilis  a  travers  les  Ages,  Ann. 
des  Maladies  Veneriennes,   1907,  ii,  501. 

8.  Butte:     Deux    Cas    d'Infection    Syphilitique    malgre    I'Emploi    pro- 
phylactique  de  la  Pommade  au  Calomel,  Le  Bull,  med.,  1908,  xxii,  114. 

9.  Behrmann:     Die    Prophylaxe    der    Syphilis   bei    Mannern,    Dermat. 
CentralbL,   1899,  iii,   172. 

10.  Cohn:  Zur  Prophylaxe  der  Syphilis  bei  Mannern,  Dermat.  CentralbL, 
1899,  iii,  237. 

11.  Richter:  Zur  Prophylaxe  der  Geschlechtlichen  Krankheiten,  Dermat. 
CentralbL,   1901-1902,  v,    130. 

12.  Loeb:  Ein  Statistischer  Beitrag  zur  Prophylaxe  der  Geschlechtlichen 
Krankheiten,  Dermat.  CentralbL,  1901-1902,  v,  322. 

13.  Max,  Joseph:  Lehrbuch  der  Prophylaxe  bei  Haut  und  Geschlechts- 
krankheiten,  1894,  Georg  Thieme,  Leipzig. 

14.  Guiard:  La  Prophylaxie  Publique  des  Maladies  Veneriennes  par 
I'Immunization  Preventive  antiseptique  des  Prostitutes,  Ann.  de  dermat. 
et  de  syph.,  1901,  ii,  1037. 

15.  Schaudinn  and  Hoffman:  Vorlaufiger  Bericht  ilber  das  Vorkommen 
von  Spirochaeten  in  Syphilitischen  Krankheitsproducten  und  bei  Papil- 
men,  Arb.  a.  d.  k.  Gsndhtsamte.,  1905,  xxii,  527. 

16.  Metchnikoff  and  Roux:  iStudes  Experimentales  sur  la  Syphilis, 
Ann.  de  I'lnst.  Pasteur,  1903,  xvii,  809. 

17.  Metchnikoff  and  Roux:  fitudes  Experimentales  sur  la  Syphilis,  Ann. 
de  rinst.  Pasteur,  1905,  xix,  683. 

18.  Metchnikoff  and  Roux:  Reche'rches  sur  la  Syphilis,  Bull,  de  I'Acad. 
de  med.,  1906,  Iv,  554. 

19.  Maissonneuve :  Experimentation  sur  la  Prophylaxie  de  la  Syphilis, 
Th^se  de  Paris,  1906,  Steinheil.  See  also  Vorberg:  Ueber  Ssrphilis  Pro- 
phylaxe, Med.  Klin.,  1916,  ii,  733. 

20.  Levy-Bing:  La  Pommade  au  Calomel  peut-elle  Prevenir  I'lnocula- 
tion  de  la  Syphilis?  Ann.  des  Maladies  Veneriennes,  1906,  i,  115. 

21.  Neisser:  Die  Experimentelle  Syphilisforschung  nach  ihrem  gegen- 
wartigen  Stande,  Verhandl.  d.  deutsch.  dermat.  Gesellsch.,  1906,  p.  83. 

22.  Metchnikoff:  Rapport  sur  la  Syphilis  Experimentale,  Verhandl.  d. 
deutsch.  dermat.  Gesellsch.,  1906,  p.  237. 

23.  Vorberg:     Ueber  SyphUis  Prophylaxe,  Med.  Klin.,  .1906,  ii,  733. 

24.  Neisser:  Pathologic  und  Therapie  der  Syphilis,  Arb.  a.  d.  k.  Gsndht- 
samte., 1911,  vol.  xxxvii,  chapter  xv. 

25.  Hugel:  fitudes  Experimentales  sur  la  Syphilis,  Ann.  des  Maladies 
Veneriennes,   1908,  iii,  47. 

26.  Koch:    Ueber  Desinfection,  Mitth.  a.  d.  k.  Gsndhtsamte.,  1881,  i,  234. 

27.  Wolfhiigel  and  V.  Knorre:  Zu  der  verschiedenen  Wirksamkeit  von 
Carbolol  und  Carbolwasser,  Mitth.  a.  d.  k.  Gsndhtsamte.,  1881,  i,  352. 

28.  Gottstein:  Sublimat-lanolin  als  Antisepticum,  Therap.  Monats., 
1880,  iii,  102. 

29.  Breslauer:  Ueber  die  antibakterielle  Wirkung  der  Salben  mit 
besonderer  Beriicksichtigung  des  Einflusses  der  Constituenten  auf  den  Desin- 
fectionswerth,  Ztschr.  f.  Hyg.  u.  Infectionskrankh.,  1895,  xx,  165. 


SYPHILIS  AND  MARRIAGE  211 

30.  Gaucher:     Encore    la    Pommade    au    Calomel,    Ann.    des    Maladies 
Veneriennes,  1906,  i,  219. 

31.  Gerson:     Bemerkungen    zu   dem  Vortrag  von  E.   Metchnikoff    iiber 
Syphilisprophylaxe,  Med.  Klin.,  1906,  ii,  467. 

32.  Bonnet:     Sur  la  Prophylaxie  de  la  Syphilis,  Thfese  de  Lyon,  1904. 

33.  Wolbarst:     A  Contribution  to  the  Subject   of   Syphilitic   Prophylaxis 
by  the  Use  of  Calomel  Ointment,  Med.  Record,  1908,  Ixxiv,  711. 

34.  Carle:     Quelques   Reflexions   Prophylactiques   Sanitaire   et    Morales, 
Lyon   med.,    1908,    ex,   289. 

35.  Acevedo:     Prophylaxe  de  la  Syphilis,  Mai.  Cutan.  et  SyphiUtiques, 
1908,  xix,  868. 

36.  Feistmantel:     Der  Personliche  Schutz  vor  Geschlechtlicher  Infection, 
Wien.  med.  Wchnschr.,  1905,  Iv,  606. 

37.  Michels:     Ein  Beitrag  zur  Prophylaxe  der  Geschlechtskrankheiten, 
Dermat.   Centralbl.,   1901-1902,  v,   226. 

38.  Wickes:     Venereal  Prophylaxis,  U.  S.  Naval  Med.  Bull.,  1907-1908, 
i-ii,  172. 

39.  Siebert:     Zur    Prophylaxe    der    Geschlechtskrankheiten,      Deutsch. 
med.  Wchnschr.,  1909,  xxxv,  677. 

40.  Davidson:     Venereal  Prophylaxis,  The  Military  Surgeon,  1912,  xxxi, 
195. 

41.  Ledbetter:     Venereal  Disease  in  the  United  States  Navy:     Preven- 
tion and  Prophylaxis,  The  Military  Surgeon,  1913,  xxxLi,  553. 

42.  Ashford,     M.:     Statistical    Report    of    Venereal    Prophylaxis,    The 
Military  Surgeon,  1914,  xxxv,  9. 

43.  Cottle:     Venereal  Disease  Aboard  Ship,  Naval  Med.  Bull.,  1915,  ix, 
571. 

44.  Riggs:     A  Study  of  Venereal  Prophylaxis  in  the  Navy,  Social  Hygiene, 
1917,  iii,  299. 

45.  Riggs:     Prevention    of   Venereal    Diseases    at   the    Naval    Training 
Station,  Norfolk,  Va.,  U.  S.  Naval  Medical  Bulletin,  1917,  xi,  1. 

46.  Exner:     Prostitution  in  its  Relation  to  the  Army  on  the   Mexican 
Border,  Social  Hygiene,   1917,  iii,  217. 

47.  Reasoner:     The  Effect  of  Soap  on  Treponema  Pallidum,  Jour.  Am. 
Med.  Assn.,  1917,  Ixviii,  973. 

48.  Brandweiner:     Statistics  of  Venereal  Diseases,  Arch.  f.   Dermat.  u. 
Syph.,  1908,  xci,  9.  Abstract  in  Ann.  des  Maladies  Veneriennes,  1908,  iii,  709. 

49.  Vedder:     The  Prevalence  of  Syphilis  in  the  Army,  Bulletin  No.  8, 
War  Department,  Office  of  the  Surgeon-General,  1915,  p.  52. 

50.  Snow,    W.    F.:     Public    Health    Measures   in   Relation    to    Venereal 
Diseases,  Jour.  Am.  Med.  Assn.,  Ixvi,  1007. 

51.  Cabot,  Hugh:     Syphilis  and  Society,  Social  Hygiene,  1916,  ii,  347. 

52.  Fournier:     Syphilis  et  Mariage,  Paris,  1880. 

53.  Finger:     Wann  Diirfen  Syphilitische  Heirathen?  Heilkunde,   1896,  i, 
338. 

54.  Nichols,  H.  J.:     The  Cure  of  Syphihs,  Bulletin  No.  3,  War  Depart- 
ment, Office  of  the  Surgeon-General,  1913,  p.  129. 


CHAPTER  IV. 
PUBLIC  HEALTH  MEASURES. 

"Myself  when  young  did  eagerly  frequent 
Doctor  and  Saint,  and  heard  great  argument,. 
About  it  and  about;  but  evermore 
Came  out  by  the  same  door  as  in  I  went." 

The  root  of  the  venereal  disease  problem  lies  in  prostitution. 
It  would  seem  that  pessimism  or  the  habit  of  looking  only  on 
the  dark  side  of  things  receives  its  justification  here,  for 
prostitution  is  a  subject  that  appears  to  have  no  bright  side. 
Nothing  is  more  discouraging  than  the  fact  that  after  so 
many  years  of  discussion  and  endeavor  to  deal  with  the 
problem  we  have  made  so  little  progress  in  practical  methods 
of  dealing  with  this  ulcer  of  the  body  politic.  The  natural 
tendency  is  to  turn  from  the  discussion  of  such  an  unprofitable 
and  disgusting  subject,  but  since  prostitution  is  the  chief 
cause  of  the  present  prevalence  of  syphilis,  any  work  dealing 
with  syphilis  and  public  health  that  omitted  this  subject 
would  be  incomplete.  While  the  discussion  of  prostitution 
must  necessarily  be  brief,  an  efi^ort  will  be  made  to  present 
sufficient  facts  to  indicate  the  hopeful  method  of  attacking 
this  problem. 

Prostitution  is  a  sociological  problem,  and  its  eradication 
depends  upon  the  study  of  the  conditions  operating  to  pro- 
duce it  and  the  adoption  of  measures  that  will  remove  these 
causes.  But  venereal  diseases  are  a  present  menace  to  society, 
and  the  sanitarian  wishes  to  know  what  practical  measures 
he  may  take  at  once  in  regard  to  prostitution  to  limit  the 
spread  of  these  diseases.  These  are  two  different  phases  of 
the  subject  that  should  be  discussed  separately. 

PROSTITUTION  AS  A  SOCIOLOGICAL  PROBLEM. 

There  is  good  reason  to  believe  that  sexual  promiscuity  is 
as  old  as  the  human  race,  since  anthropologists  tell  us  that 


PROSTITUTION  AS  A  SOCIOLOGICAL   PROBLEM     213 

before  the  development  of  the  family  promiscuity  was  general, 
and  our  knowledge  of  the  animals  from  which  the  human  race 
developed  appears  to  confirm  this  view.  Therefore  promis- 
cuity or,  at  least,  polygamy  is  biologically  a  natural  con- 
dition, and  monogamy  has  developed  as  the  result  of  moral 
and  economic  considerations.  But  the  latter  have  not  as 
yet  been  sufficient  to  entirely  restrain  man  from  his  tendency 
to  promiscuity,  and  this  is  the  ultimate  cause  of  prostitution. 

The  origin  of  venereal  diseases  is  shrouded  in  obscurity. 
Promiscuity  among  the  animals  is  not  productive  of  disease 
with  the  single  excejption  of  dourine,  or  so-called  horse 
syphilis,  which  is  a  trypanosome  infection  transmitted  by 
sexual  congress.  But  it  is  useless  to  speculate  upon  the 
biological  origin  of  venereal  diseases.  Gonorrhea  at  least  is 
known  to  have  existed  from  early  antiquity.  Many  have 
thought  that  syphilis  was  brought  back  from  America  by  the 
sailors  with  Columbus  and  thence  spread  over  Europe,  but 
there  is  no  proof  that  this  view  is  correct.  In  no  case  has 
undoubted  syphilis  been  demonstrated  in  pre-Columbian 
bones,  while,  on  the  contrary,  there  is  considerable  evidence 
that  syphilis  was  common  in  Europe  before  the  discovery  of 
America  but  was  not  distinguished  as  an  independent  disease, 
being  confounded  with  leprosy  and  other  diseases.  Mercurial 
inunctions  were  a  popular  form  of  treatment  in  Europe  long 
before  the  time  of  Columbus,  and  it  is  difficult  to  understand 
to  what  their  popularity  was  due  if  syphilis  was  non-existent. 
But  while  there  are  differences  of  opinion  on  this  point  which 
can  hardly  be  regarded  as  settled,  there  are  certainly  grounds 
for  believing  that  sexual  promiscuity  with  its  accompaniment 
of  venereal  disease  has  been  with  us  since  before  the  dawn  of 
history.  If  sexual  promiscuity  ceased,  gonorrhea  and  syphilis 
would  soon  become  extinct  diseases.  But  since  the  human 
race  has  made  so  little  moral  progress  in  its  long  development 
through  the  ages  it  is  hardly  to  be  expected  that  a  sudden 
revolution  in  morals  will  occur  during  the  present  generation. 

This  does  not  mean  that  we  should  not  "  hitch  our  chariot 
to  a  star. "  Ideals  are  our  most  precious  asset,  and  it  is  well 
to  have  clearly  before  us  the  ideal  of  a  community  free  from 
vice,  and  the  education  of  a  new  race  of  men  who  will  have 


214  PUBLIC  HEALTH  MEASURES 

the  same  standard  of  sexual  purity  for  themselves  as  for  the 
women  they  expect  to  marry.  But  it  is  well  to  remember 
that  such  high  ideals  are  only  slowly  realized,  and  that  in  the 
meantime  we  are  compelled  to  live  in  the  world  as  it  exists 
today. 

Sociological  Reform. — Since  the  raison  d'etre  of  prostitution 
is  to  be  found  in  the  biological  origin  of  the  race  and  the 
struggle  between  a  perfectly  natural  appetite  and  moral  and 
economic  laws,  it  follows  that  any  conditions  that  make 
marriage  easy  will  proportionately  reduce  prostitution,  while 
those  social  conditions  that  make  marriage  difficult  or  defer 
the  age  of  marriage  encourage  prostitution.  In  primitive 
communities  where  marriage  occurs  at  an  early  age  prosti- 
tution is  almost  unknown.  When  the  community  becomes 
more  complex,  as  in  cities,  the  age  of  marriage  is  almost 
always  deferred.  The  man  who  derives  his  living  from  the 
soil  in  a  country  where  land  is  easily  obtainable  may  be 
economically  independent  and  may  marry  at  the  age  of' 
twenty  or  earlier.  In  the  city  a  long  period  of  intensive 
education  becomes  necessary  before  economic  independence 
can  be  achieved,  and  the  age  at  which  marriage  is  possible 
is  deferred  for  from  five  to  ten  years.  Reproduction  is  a 
physiological  possibility  at  a  very  early  age  (puberty),  and  if 
governed  solely  by  physiological  laws  would  normally  occur 
not  much  later  than  eighteen  years  of  age.  The  perpetuation 
of  the  species  is  not  dependent  on  the  whims  of  individuals, 
but  is  ensured  by  means  of  a  most  imperious  instinct,  the  sex 
appetite.  This  appetite  is  far  stronger  in  the  male  than  in  the 
female,  and  hence  we  find  that  it  is  almost  always  the  male 
who  seeks  his  mate.  If  this  instinct  were  promptly  obeyed 
in  a  legitimate  way,  marriage  would  generally  occur  some- 
where between  eighteen  and  twenty  years  of  age.  But 
physiology  and  sociological  conditions  are  not  on  speaking 
terms  and  make  their  arrangements  quite  independently, 
and  as  both  are  equally  imperious  and  exigent,  prostitution 
is  the  natural  result.  The  demand  on  the  part  of  the  male 
creates  the  supply  and  will  continue  to  do  so  until,  as  the 
result  of  education  to  a  higher  moral  plane  or  changed 
economic  conditions,  the  demand  ceases. 

It  is  frequently  stated,  and  very  generally  believed,  that 


PROSTITUTION  AS  A  SOCIOLOGICAL  PROBLEM     215 


women  are  driven  into  prostitution  because  they  are  not 
paid  a  living  wage.  This  may  occasionally  be  a  cause  of 
prostitution,  but  it  is  a  very  minor  cause,  as  shown  by 
investigations  into  the  previous  occupations  of  prostitutes. 
Stromberg  found  that  out  of  462  prostitutes  there  was  not  a 
single  case  in  which  the  economic  cause  was  the  determining 
factor.  Welander  in  his  studies  of  prostitutes  in  Stockholm 
found  that  60  per  cent,  of  them  were  previously  in  domestic 
service  and  were  in  comfortable  circumstances.  Leonhard's 
examination  of  the  records  of  600  prostitutes  in  Diisseldorf 
failed  to  establish  poverty  as  a  reason  for  prostitution. 
Kneeland  found  that  at  the  Bedford  Reformatory  out  of  279 
cases  economic  conditions  were  thought  to  be  responsible 
for  the  adoption  of  a  life  of  prostitution  in  only  19  cases.^ 

We  see,  therefore,  that  very  few  prostitutes  allege  poverty 
as  a  compelling  cause.  A  very  large  percentage  come  from 
the  ranks  of  domestics,  who  may  not  be  richly  paid,  and  whose 
hours  of  labor  may  be  hard,  but  who  are  at  least  fed,  clothed 
and  housed  and  cannot  have  been  driven  into  prostitution 
by  destitution.  There  may  be  a  thousand  contributing 
causes,  including  the  fact  that  many  girls  who  are  mentally 
deficient  or  morally  weak  find  this  life  an  easier  mode  of 
support  than  more  legitimate  occupations;  but  the  essential 
cause  is  the  demand  on  the  part  of  the  male  that  his  sexual 
appetite  be  satisfied,  and  as  legitimate  marriage  is  impossible, 
prostitution,  the  white  slave  traffic  and  venereal  disease  are 
the  natural  consequences. 

That  prostitution  is  supported  almost  wholly  by  the 
unmarried  is  shown  by  the  following  figures  compiled  by 
Brandweiner:^ 

MALES. 


Widowed  or 

Disease. 

Total. 

Single. 

Married. 

divorced. 

Chancroid 

.      .        980 

895 

75 

10 

Gonorrhea 

.      .      1365 

1179 

162 

24 

Syphilis 

.      .      2264 

1962 

270 

32 

FEMALES. 

Widowed  or 

Disease. 

Total. 

Single. 

Married. 

divorced. 

Chancroid 

.      .        941 

906 

29 

6 

Gonorrhea 

.      .     1670 

1618 

43 

9 

Syphilis 

.      ,     2900 

2660 

210 

30 

216  '^      PUBLIC  HEALTH  MEASURES 

We  have  already  seen  that  the  great  majority  of  venereal 
diseases  are  derived  directly  from  prostitution,  and  the 
prevalence  of  these  diseases  among  the  single  is  a  sure  indi- 
cation that  it  is  the  unmarried  who  turn  to  prostitution. 
The  fact  that  the  greatest  incidence  of  venereal  diseases  is 
between  the  years  of  twenty-one  to  twenty-five  indicates 
that  it  is  just  during  these  years,  when  marriage  should  have 
occurred,  that  most  of  the  exposures  have  taken  place. 

Further  evidence  that  the  prostitute  draws  her  clientele 
chiefly  from  the  unmarried  may  be  found  in  statistics  presented 
by  Snow.^  During  one  year  369  new  cases  were  classified  in 
a  Boston  dispensary  for  venereal  diseases,  with  the  following 
result:  those  single  under  twenty-one  years  comprise  23.5  per 
cent,  of  all  cases,  single  over  twenty-one  years  65  per  cent, 
of  all  cases,  so  that  88.5  per  cent,  were  single.  The  married 
under  thirty  years  furnished  only  6  per  cent,  and  over  thirty 
years  5.5  per  cent.,  so  that  the  total  married  cases  were  11.5 
per  cent.  In  the  same  article  it  is  shown  that  the  source  of 
infection  in  55.5  per  cent,  of  cases  is  the  prostitute;  that 
domestics,  friends,  working  women  and  unknown  sources 
were  responsible  for  42.4  per  cent.,  and  that  only  1.5  per  cent, 
of  the  cases  of  venereal  disease  were  traceable  to  adulterous 
relations  with  married  women. 

If  this  statement  of  the  cause  of  prostitution  is  correct  it 
affords  little  hope  that  this  evil  will  be  eradicated  in  the  near 
future.  Numerous  writers  have  advised  that  earlier  marri- 
ages should  be  encouraged.  This  is  much  like  encouraging 
us  to  keep  cool  in  the  summer  with  the  thermometer  at  95  ° 
or  advising  a  sick  pauper  that  a  sea  voyage  would  benefit 
him.  Earlier  marriage,  however  desirable  this  may  be,  will 
hardly  be  made  possible  without  a  radical  change  in 
economic  conditions.  Incidentally  it  may  be  emphasized  that 
sanitation  is  more  closely  united  with  economic  problems 
than  is  generally  realized.  If  we  study  tuberculosis  or  infan- 
tile mortality  in  the  cities  we  at  once  encounter  the  housing 
problem.  Overcrowding  in  the  cities  will  have  to  be  pre- 
vented and  suitably  spacious  habitations  provided  before 
these  and  other  diseases  can  be  reduced  much  below  their 
present  levels.     Malaria  in  the  South  resolves  itself  into 


PROSTITUTION  AS  A  SOCIOLOGICAL   PROBLEM     217 

communities  too  poor  to  provide  proper  drainage  and  screen- 
ing or  to  secure  proper  treatment.  The  eradication  of  beri- 
beri in  the  Orient  is  purely  an  economic  problem,  entailing 
the  substitution  of  undermilled  rice  or  other  beri-beri-pre- 
venting  foods  for  the  too  exclusive  use  of  the  highly  milled 
and  beri-beri-producing  rice,  which  for  the  most  part  is  eaten 
because  the  natives  are  too  poor  to  purchase  a  more  liberal 
diet.  Economic  changes  are  in  the  air,  and  the  time  may  come 
sooner  than  we  expect  when  there  will  no  longer  be  any 
abject  poverty,  with  its  accompaniment  of  disease,  and  con- 
ditions may  then  become  so  changed  that  young  people  can 
marry  earlier.  In  the  meantime  the  sanitary  officer  cannot 
expect  any  assistance  from  this  direction. 

Even  granted  that  marriage  must  be  delayed,  prostitution 
would  be  eradicated  if  we  could  educate  our  young  men  to 
abstain  from  irregular  sexual  relations  before  marriage,  and 
this  brings  us  naturally  to  the  subject  of  education. 

Education. — ^The  proper  type  of  education  is  of  the  greatest 
value  in  the  prevention  of  immorality  and  of  venereal  diseases. 
But  in  recent  years  the  idea  has  developed  that  general  sex 
education  of  the  young,  and  particularly  instruction  as  to  the 
nature  and  consequences  of  venereal  diseases,  would  prove 
efficacious.  Anyone  who  opposes  sex  education  of  the 
young  today  is  in  danger  of  being  classed  as  a  dangerous 
reactionary,  yet  I  feel  sure  that  unless  this  instruction  is  prop- 
erly given,  which  is  most  difficult,  that  it  will  do  more  harm 
than  good.  Some  of  it  excites  morbid  curiosity,  and  there 
is  a  peculiar  twist  to  human  nature  that  drives  most  of  us 
to  want  to  do  anything  that  we  are  specifically  charged  or 
advised  not  to  do.  The  general  reluctance  of  parents  and 
teachers  to  discuss  sex  matters  with  the  young  is  ascribed 
by  many  to  prudery,  but  I  believe,  on  the  contrary,  it  is 
a  safe  instinct  to  follow.  Experience  indicates  that  there  is 
more  venery  among  Latin  races,  among  whom  discussion  of 
sex  topics  is  more  or  less  open,  than  among  Anglo-Saxon 
races,  where  the  sex  topic  is  taboo  and  where  jokes  such  as 
are  freely  published  in  La  Rire  would  cause  the  suppression 
of  the  journal. 

Admitting  that  a  certain  amount  of  sex  information  is 


218  PUBLIC  HEALTH  MEASURES 

desirable  for  children,  it  should  be  supplied  by  parents,  and 
such  instruction  has  no  place  in  schools  below  the  rank  of 
colleges. 

Mr.  Mark  Sullivan  wrote  in  Collier's  as  follows:  "It  seems 
clear  that  experience  so  far  shows  that  the  whole  problem 
of  sex  had  better  be  approached  in  the  spirit  of  personal 
reserve  that  w^e  associate  with  the  better  sort  of  home  life 
rather  than  in  the  spirit  of  eager  curiosity  and  practical  experi- 
mentation that  we  associate  with  the  school.  .  .  .  Any 
system  of  instruction  which  gives  a  knowledge  of  sex  hygiene 
merely  as  mechanical  knowledge  will  be  a  great  mistake.  Any 
instructors  given  this  responsibility  must  have  the  spiritual 
force  to  conquer  these  problems  and  the  personality  to  com- 
pel their  pupils  to  reverence.  Anything  less  will  be  instruction 
for  dogs,  not  for  human  beings."  To  these  sentiments  we 
unhesitatingly  subscribe. 

The  idea  that  sex  education  will  prevent  venereal  diseases 
is  based  upon  the  belief  that  men  did  not  realize  the  dangers 
of  infection,  and  in  instructing  young  men  efforts  have  been 
made  to  depict  the  most  frightful  ravages  of  venereal  diseases 
with  the  purpose  of  instilling  a  wholesome  fear.  It  seems  to 
me  that  such  efforts  are  futile.  There  is  plenty  of  evidence 
to  show  that  even  one  attack  of  a  venereal  disease  does  not 
act  as  a  deterrent  to  future  immorality,  and  medical  students 
who  are  presumably  informed  are  no  more  moral  than  other 
members  of  the  student  body.  The  average  youth  knows  the 
danger  of  infection,  but  he  either  ignores  it  or  is  sufficiently 
egotistic  to  believe  that  either  he  or  his  mistress  is  different, 
and  that  he  will  escape  the  contagion  that  is  visited  upon 
weaker  vessels.  We  have  already  discussed  this  subject  in  a 
previous  chapter,  and  concluded  that  fear  is  a  poor  deterrent. 

For  these  reasons  no  great  results  can  be  expected  of  such 
sex  education.  The  only  education  that  will  effect  a  reduction 
in  immorality  is  the  education  that  forms  character  and,  as 
Huxley  says,  "Molds  the  desire  to  live  in  accordance  with 
the  laws  of  nature. "  Such  education  we  have  always  had. 
It  is  true  that  such  education  has  often  been  insufficient  in 
quantity,  while  some  individuals  have  escaped  it  entirely, 
and  that  we  must  do  all  in  our  power  to  increase  the  facilities 


THE  CONTROL  OF   VENEREAL  DISEASES         219 

for  such  education.  But  it  is  hopeless  to  expect  that  any 
great  immediate  reduction  in  the  amount  of  immorahty  and 
the  number  of  venereal  diseases  will  be  effected  by  our  present 
attempts  in  that  direction. 

THE  CONTROL  OF  VENEREAL  DISEASES. 

At  the  present  day  the  sanitarian  is  confronted  with  the 
problem  of  the  present  prevalence  and  dissemination  of 
venereal  diseases,  the  magnitude  of  which  we  have  already 
partly  seen.  Faced  by  this  problem  the  sanitarian  may  take 
the  attitude  of  the  ostrich  or  that  assumed  by  Mr.  Podsnap 
and  refuse  to  entertain  the  disagreeable  topic.  _  Or  he  may 
proceed  to  take  active  measures  against  the  evil.  In  either 
case  the  sanitary  officer  will  be  criticized,  and  knowing  that 
this  criticism  will  be  aimed  at  him,  his  position  must  be  care- 
fully thought  out,  and  he  must  be  convinced  that  the  measures 
he  proposes  to  take  will  be  efficient,  wih  be  practicable  and 
will  not  be  immoral.    How  shall  he  deal  with  prostitution? 

In  the  first  place  it  is  apparent  that  though  he  may  be 
in  sympathy  M^th  economic  and  moral  reform  and  may  do 
all  in  his  power  to  further  it,  his  problem  is  not  the  eradication 
of  prostitution  but  the  limitation  of  venereal  disease.  Pros- 
titution is  a  sociological  problem  that  is  only  to  be  solved  with 
time  and  the  evolution  of  the  community  to  a  higher  moral 
plane.  In  the  meantime  the  sanitary  officer  wishes  to  take 
some  steps  toward  reducing  the  prevalence  of  venereal  dis- 
eases, and  his  only  dealings  with  prostitution  are  dhected 
toward  that  end,  though  the  measures  he  adopts  should  not 
be  out  of  harmony  with  the  aspirations  toward  social  reform. 

In  the  past,  reformers  and  sanitarians  have  been  able  to 
find  no  common  ground  upon  which  to  stand  in  dealing  with 
this  question.  This  is  not  only  because  there  are  at  least 
two  sides  to  every  question,  but  because  our  conception  of  the 
problem  and  the  attitude  we  take  toward  it  is  inevitably 
based  quite  as  much  upon  our  feelings  and  our  training_  as 
upon  cold  reason.  There  are  inevitable  differences  of  opinion 
with  regard  to  ethical  questions,  and  it  need  cause  no  surprise, 
therefore,  that  there  have  been  differences  of  opinion  in  regard 


220  PUBLIC  HEALTH  MEASURES 

to  the  morality  of  various  measures  that  have  been  applied 
to  prostitution  for  the  purpose  of  reducing  the  venereal 
infections.  The  practical  sanitarian  is  inclined  to  insist  that 
we  must  strip  the  question  of  its  moral  aspects  and  treat 
venereal  diseases  like  any  other  infectious  disease.  The 
moralist  replies  that  this  cannot  be  done,  and  it  appears  to 
me  that  both  are  only  half-right. 

Venereal  diseases  are  not  like  other  infectious  diseases 
because  they  do  involve  a  moral  principle.  It  is  often  argued 
that  this  does  not  hold  because  there  are  a  large  number  of 
innocent  infections  with  both  syphilis  and  gonorrhea.  The 
percentage  of  innocent  infections  is  not  absolutely  laiown,  but 
granting,  for  the  sake  of  argument,  that  50  per  cent.. of  the 
venereal  infections  are  innocently  acquired,  how  can  we  ignore 
the  moral  side  of  the  question  so  long  as  the  remaining  50 
per  cent,  are  due  to  immorality?  Moreover,  every  case  of 
venereal  disease  is  at  most  but  two  or  three  removes  from 
immorality.  The  wife  suffers  from  an  innocent  infection,  but 
the  husband  acquired  the  disease  directly  as  the  result  of 
illicit  intercourse. 

Yet  those  who  conhne  themselves  to  high  moral  concepts 
without  suggesting  any  practical  method  to  help  their  fellow- 
sufferers  are  equally  in  the  wrong.  Neglect  to  act  is  quite  as 
culpable  as  an  erroneous  action,  as  is  illustrated  by  the 
priest  and  the  Levite  who  went  by  on  the  other  side.  With 
these  as  our  principles,  what  measures  can  be  taken  to  reduce 
the  venereal  disease  that  results  from  prostitution? 

Excluding  sociological  reform,  with  which  the  sanitarian 
is  not  immediately  concerned,  there  are  apparently  only 
four  ways  of  dealing  with  this  problem,  namely,  laissez- 
faire,  suppression,  regulation  and  a  method  that  has  never 
yet  been  tried,  the  systematic  treatment  of  all  infected. 

The  practice  in  this  country  has  in  general  been  confined 
to  laissez-faire,  varied  by  spasmodic  attempts  at  suppression. 
This  policy  is  responsible  for  the  present  prevalence  of 
venereal  diseases,  and  since  we  are  attempting'to  improve  this 
situation,  and  since  it  can  hardly  be  called  a  policy  but  is 
rather  the  result  of  indifference,  it  is  unnecessary  to  consider 
this  method  further. 


THE  CONTROL  OF   VENEREAL  DISEASES  221 

Suppression. — At  the  present  stage  of  our  sociological 
development,  suppression  does  not,  and  probably  cannot, 
suppress.  Virtue  cannot  be  secured  by  legislation,  and  efforts 
to  change  morals  by  legislation  will  fail  so  long  as  public 
opinion  does  not  support  them.  Instead  of  correcting  the 
abuse  aimed  at,  such  laws  frequently  result  in  the  dissemina- 
tion of  immorality  and  vice,  the  corruption  of  the  police, 
and  the  failure  to  enforce  the  law  breeds  contempt  for  it. 
Those  who  believe  in  suppression  do  not  deny  these  general 
principles.  They  reply  that  laws  against  murder  do  not 
prevent  murder  entirely,  but  they  do  make  it  less  frequent 
and  help  us  to  punish  it  when  it  does  occur.  Repressive 
ordinances  against  prostitution,  while  not  suppressing  it 
entirely,  drive  the  traffic  into  obscurity  and  reduce  it  to  a 
minimum.  Vice  is  not  flaunted  in  public  but  is  driven  into 
corners  where  the  vicious  will  find  it,  but  where  it  will  not 
entice  the  innocent  and  unwary. 

I  believe  this  argument  loses  sight  of  the  fact  that  we  can 
only  have  laws  enforced  in  so  far  as  they  are  in  accord  with 
public  sentiment.  The  law  against  murder  is  an  accurate 
expression  of  public  sentiment,  and  yet  it  lags  in  its  execution, 
for  it  is  only  the  exceptional  murderer  who  is  detected,  and 
when  detected  he  frequently  escapes  conviction,  and  after 
conviction  he  is  often  pardoned.  Can  we  say  that  even  this 
law  is  well  enforced?  The  enforcement  of  laws  that,  on  the 
contrary,  are  written  on  the  statute  books  in  defiance  of  public 
sentiment  is  a  scandal.  The  law  against  Sunday  opening  of 
saloons  in  a  city  where  the  majority  of  the  population  want 
them  open  is  never  enforced  except  by  an  occasional  spasm. 
Laws  or  regulations  for  the  suppression  of  prostitution  are 
necessarily  enforced  in  the  same  spasmodic  way,  for  while 
we  may  not  like  to  admit  it,  the  demand  for  the  prostitute 
is  quite  as  strong  as  the  demand  for  liquor. 

In  the  Chicago  Vice  Report  it  is  estimated  that  1012 
women  on  the  police  lists  received  over  15,000  visits  a  day, 
or  5,500,000  a  year,  and  these  women  constituted  only  one- 
fifth  of  the  professional  prostitutes  of  Chicago.  If  the  average 
continues  then  the  5000  prostitutes  of  Chicago  were  receiving 
more  than  25,000,000  visits  a  year.    And  these  professionals 


222  PUBLIC  HEALTH  MEASURES 

did  not  begin  to  represent  the  whole  ilHcit  traffic  of  the  city, 
as  it  is  admitted  that  clandestine  prostitution  and  occasional 
vice  were  beyond  all  measurement.  This  gives  some  idea  of 
the  enormity  of  the  impulse  and  demand  behind  the  social 
evil,  which  it  is  proposed  to  repress  and  ultimately  to  anni- 
hilate. As  the  Commission  states :  "  So  long  as  there  is  lust 
in  the  hearts  of  men  it  will  seek  out  some  method  of  expres- 
sion. Until  the  hearts  of  men  are  changed  we  can  hope  for 
no  absolute  annihilation  of  the  social  evil.'/ 

We  can  judge  of  the  effect  of  suppressive  ordinances  by 
observing  the  effects  of  the  prohibition  of  liquor.  William 
Allen  White,  in  a  discussion  on  prohibition  in  Kansas,  in 
which  he  concludes  that  prohibition  is  a  success^  says: 
"  Prohibition,  of  course,  does  not  prohibit.  Nothing  has  hurt 
the  cause  of  temperance  in  this  country  so  seriously  as  the 
delusion  that  a  law  on  the  statute  book  will  prohibit  the  sale 
of  liquor  in  a  city,  a  county  or  a  State.  A  prohibitory  law 
only  gives  men  and  women  who  desire  prohibition  an  oppor- 
tunity to  secure  it  by  long  years  of  wise,  brave,  hard  work." 

'Even  less  is  to  be  expected  from  the  attempt  to  suppress 
prostitution,  because  while  the  fight  on  liquor  has  been 
conducted  in  the  open,  with  all  the  great  assistance  of  the 
widest  publicity,  the  campaign  against  prostitution  has 
never  as  yet  been  given  this  wide  publicity.  It  is  a  filthy 
subject,  avoided  by  all  public  prints  and  by  most  of  the 
people  who  unhesitatingly  enter  the  fight  against  the  liquor 
traffic.  If  therefore  we  are  not  ready  to  enter  a  long  and 
hard  campaign  against  prostitution,  laws  for  suppression 
cannot  be  enforced,  and  if  not  enforced,  they  amount  to  no 
more  than  laissez-faire. 

Spasms  of  virtue  on  the  part  of  a  community  do  harm 
rather  than  good,  because  nothing  is  accomplished  either 
for  morals  or  hygiene  by  transferring  immorality  from  the 
brothel  to  the  street  and  stopping  there,  while  under  these 
conditions  many  people  actually  delude  themselves  into  the 
belief  that  something  definite  has  been  accomplished. 

The  recent  experience  of  the  city  of  Washington  is  a  con- 
crete illustration  of  the  force  of  this  argument.  A  notorious 
red-light  district  had  existed  in  one  of  the  most  public  and 


THE  CONTROL  OF   VENEREAL  DISEASES         223 

frequented  portions  of  the  city  for  many  years.  Congress 
decided  that  this  state  of  affairs  should  not  continue,  and  on 
February  7,  1914,  passed  the  so-called  Kenyon  law,  an  act 
to  enjoin  and  abate  houses  of  lewdness,  assignation  and 
prostitution.  As  the  result  of  this  act  the  red-light  district 
was  wiped  out,  but  no  provision  was  made  to  supply  a  legiti- 
mate occupation  for  the  inmates.  WTien  the  bill  went  into 
operation  most  of  the  prostitutes  took  a  train  out  of  town. 
No  one  seems  to  have  questioned  the  morality  of  unloading 
undesirables  upon  a  neighboring  community.  But  most 
of  these  women  took  a  return  train  to  Washington  and  are 
now  scattered  throughout  the  residential  districts  and  in 
apartment  houses.  Physicians  and  police  officials  who  are 
in  a  position  to  know  assure  me  that  there  are  just  as  many 
public  women  in  Washington  today  as  before  the  district 
was  closed.  Nor  has  venereal  disease  been  perceptibly 
diminished.  The  various  specialists  in  these  diseases  see 
the  same  number  of  cases  now  as  formerly,  and  in  the  army 
posts  near  the  city,  where  the  men  who  expose  themselves 
are  required  to  report  at  the  hospital  for  prophylactic 
treatment,  there  have  been  just  as  many  prophylactic  treat- 
ments given  as  before  the  district  was  closed. 

It  appears  logical  to  conclude  that  the  sanitary  officer 
should  not  oppose  efforts  directed  at  the  suppression  of  pros- 
titution, especially  when  such  efforts  represent  the  moral 
sense  of  the  community  and  not  only  the  desires  of  a  few 
reformers.  But  he  is  under  an  obligation  to  point  out  that 
such  efforts  have  usually  failed,  that  they  are  sure  to  fail 
unless  the  public  will  insist  on  and  work  for  the  enforcement 
of  the  law,  not  for  a  few  weeks  or  months  but  continuously. 
And,  finally,  he  should  insist  that  as  even  rigid  enforcement 
of  the  law  cannot  be  expected  to  eradicate  either  clandestine 
prostitution  or  immorality,  that  there  should  be  ample 
provision  for  the  diagnosis  and  treatment  of  venereal  dis- 
eases, particularly  syphilis. 

For  the  eradication  of  prostitution  we  must  wait  until 
humanity  has  been  educated  to  that  moral  plane  where 
sexual  appetite  shall  be  brought  to  heel  by  an  inflexible  will 
acting  at  the  behest  of  high  morality.    Granting  that  educa- 


224  PUBLIC  HEALTH  MEASURES 

tion  may  eventually  result  in  such  sociological  progress, 
this  result  will  only  be  obtained  in  the  distant  future.  In  the 
meantime,  prostitution  is  to  remain  with  us,  its  prevalence 
little  if  at  all  diminished  by  repressive  measures.  What 
possibilities  lie  in  regulation? 

Segregation  and  Reglementation. — It  is  obvious  that  regu- 
lation cannot  be  attempted  in  the  presence  of  repressive 
measures,  since  regulation  presupposes  the  recognition  by  the 
law  of  a  traffic  that  while  obnoxious  cannot  be  suppressed. 

At  the  outset  it  may  be  safely  stated  that,  reviewing  the 
history  of  prostitution,  and  the  sanitary  measures  taken  to 
prevent  venereal  disease  as  a  result  of  prostitution,  "prac- 
tically every  attempt  to  control  either  the  one  or  the  other, 
whether  by  segregation,  medical  inspection  or  by  whatever 
means  attempted,  has  been  a  fiasco."  This  fact  is  generally 
admitted,  and  is  clearly  brought  out  in  Abraham  Flexner's 
work  on  Prostitution  in  Europe. 

Flexner  and  others  believe  that  this  failure  is  inherent  in 
any  attempt  to  regulate  prostitution.  It  is  therefore  perti- 
nent to  raise  the  question  whether  this  is  the  case  or  whether 
the  failure  in  the  instances  cited  was  not  due  to  the  method 
in  which  regulation  was  applied. 

In  order  to  answer  this  question  it  is  necessary  to  consider 
the  criticisms  that  have  been  directed  at  the  various  systems 
that  have  been  adopted.  These  may  be  considered  in  the 
following  order: 

I.  Criticisms  of  the  manner  in  which  regulation  has  been 
applied. 

1.  Because  the  medical  inspection  and  control  of  prosti- 
tutes has  been  so  superficial  and  inadequate  as  to  be  a  farce. 
Thus  Flexner  says  with  regard  to  the  Paris  examination: 
"All  day  long  a  dismal  succession  of  groups  of  abandoned 
women  file  into  the  rudely  equipped  rooms,  in  which  two 
physicians  ply  their  repellent  task  perfunctorily.  A  line  is 
formed;  with  open  jaws  and  protruding  tongue  they  march 
rapidly  past;  the  doctor  uses  one  spatula  for  all,  wiping  it 
hastily  on  a  soiled  towel  from  time  to  time.  This  finished, 
the  same  group  in  quick  succession  ascend  two  surgical  chairs 
to  permit  a  cursory  vaginal  inspection;  the  physician,  station- 


THE  CONTROL  OF   VENEREAL  DISEASES         225 

ing  himself  between  them,  loses  no  time,  for  one  woman  is 
assuming  the  recumbent  position  while  he  is  engaged  in 
the  examination  of  another;  he  switches  back  and  forth  as 
rapidly  as  the  women  can  get  up  and  down — indulging  in 
good-humored  and  sometimes  unseemingly  jocularity  as  the 
work  proceeds.  Of  the  two  physicians  employed  on  the 
occasion  of  one  of  my  visits,  one  used  a  rubber  glove,  the 
other  a  rubber  finger — in  both  cases  the  same  for  all ;  though 
wiped  on  a  towel  from  time  to  time,  neither  was  changed 
or  cleansed.  On  one  occasion  I  observed  one  of  the  physicians 
examine  twenty-five  to  thirty  girls  without  changing,  washing 
or  wiping  the  rubber  fingers  he  wore,  and  a  number  of  those 
examined  were  adjudged  "diseased."  The  speculum  was 
rarely  used.  In  one  instance  pressure  by  the  finger  on  the 
urethra  discharged  an  abundant  suspicious  secretion;  the 
same  finger,  unwashed,  was  used  in  examining  the  next  case; 
in  another  instance  the  same  rubber  finger  was  used  on  the 
genitalia  and  about  the  mouth.  The  inspections  consumed 
from  fifteen  to  thirty  seconds  each.  "For  vaginal  examina- 
tions," so  read  my  notes  made  on  the  spot,  "it  takes  less 
time  to  examine  one  woman  than  it  takes  another  to  mount 
the  examining  chair  and  ofi^er  herself  for  examination,  despite 
the  fact  that  her  clothing  has  been  adjusted  before  entering 
the  room." 

This  is  medical  inspection  at  its  worst!  As  Flexner  says, 
the  clinical  method  is  utterly  incompetent  to  detect  any 
considerable  portion  of  infectious  disease.  "Giith  tells  of  a 
series  of  cases,  35  per  cent,  of  which  showed  clinical  symp- 
toms of  gonorrhea;  the  microscope  showed  90  per  cent." 
"Dr.  Moller,  of  Stockholm,  states  that  in  1874,  19  cases 
of  gonorrhea  were  found  among  298  prostitutes  by  clinical 
methods  (6  per  cent.) ;  partial  use  of  the  microscope  in  1904, 
with  408  registered  women  revealed  749  cases,  or  174  per 
cent."*  "This  being  the  result  of  incomplete  use  of  the 
microscope,  to  how  much  infection  did  the  privileges  con- 
ferred by  regulation  lead  in  Cologne  in  the  year  1905,  when 
among  2048  prostitutes  examined  in  the  course  of  the  year 

*  Many  of  these  women  must  have  been  found  positive  repeatedly. 
15 


226  PUBLIC  HEALTH  MEASURE;^ 

148  {i.  e.,  7.2  per  cent.)  were  pronounced  venereally  diseased? 
Or  at  Vienna,  when,  out  of  2116  enrolled  women,  87  were 
found  to  be  suffering  with  gonorrhea  and  162  with  syphilis 
in  the  course  of  the  year  1907." 

These  criticisms  are  all  justified.  The  fact  is  that  medical 
inspection  and  regulation  as  it  has  been  practised  in  the 
past  has  generally  been  utterly  farcical  and  inefficient. 
The  bad  results  obtained  from  this  inefficient  regulation 
should  not,  however,  close  our  eyes  to  the  fact  that  an 
efficient  inspection  is  possible  at  least  so  far  as  the  medical 
side  of  it  is  concerned. 

Thus,  in  some  other  cities  Flexner  found  the  inspection 
to  be  much  more  efficient.  In  Berlin,  Flexner  says,  "Women 
under  control  are  required  to  report  to  police  headquarters 
for  examination  twice  weekly  if  under  twenty-four  years 
of  age;  once  a  week  if  between  twenty-four  and  thirty-four 
years  of  age,  and  fortnightly  if  over  thirty-four.  In  addition, 
the  inscribed  or  controlled  prostitute  is  reexamined  when- 
ever arrested  for  any  offence,  regardless  of  the  date  of  her 
last  or  her  next  regular  examination.  Clandestine  prosti- 
tutes may  be  subjected  to  compulsory  examination  at  the 
discretion  of  the  bureau  chief,  the  examination  being  con- 
ducted by  a  woman  physician  attached  to  the  division  for 
this  purpose.  By  special  request  an  examination  by  an 
approved  private  physician  may  be  substituted.  In  either 
event  the  woman  herself  is  at  no  expense  for  the  examination. 

A  staff  of  eight  police  physicians  and  four  microscopists 
are  occupied  with  medical  inspection,  of  whom  four  are  on 
duty  at  one  time;  the  work  goes  on  daily,  except  Sunday, 
from  nine  to  twelve  o'clock  and  from  twelve  to  three.  The 
examination  consists  of  a  clinical  inspection  and  the  use  of 
the  speculum.  For  the  detection  of  gonorrhea,  microscopic 
examinations  of  the  secretions  are  made  fortnightly  in  case 
of  women  under  thirty-four;  monthly,  in  case  of  older 
women.  At  any  time,  however,  when  appearances  are 
suspicious,  the  physician  is  instructed  to  ask  for  microscopic 
examination  without  waiting  for  the  regular  day.  Female 
assistants  are  provided  for  this  work;  the  word  of  the  assistant 
is  sufficient  in  case  the  microscopic  preparation  is  found  to 


THE  CONTROL  OF   VENEREAL  DISEASES  227 

be  negative;  the  physician  must  by  his  own  observation 
confirm  a  positive  result.  The  medical  policy  of  the  police 
department  is  directed  by  a  physician  who  holds  the  rank 
of  commissary,  the  sole  instance  in  all  Europe  of  medical 
control  of  what  is  admittedly  a  sanitary  matter. 

Inscribed  women  discovered  to  be  infected  are  confined 
under  duress  in  a  municipal  hospital,  on  the  theory  that, 
being  professional  prostitutes,  who  can  maintain  themselves 
only  by  plying  their  business,  they  must  be  interned  in  order 
that  the  carrying  on  of  their  business  may  be  temporarily 
suspended.  In  very  rare  cases,  however,  even  when  found 
to  be  diseased,  they  are  permitted  to  retain  their  freedom 
provided  an  approved  physician  makes  himself  responsible 
for  their  systematic  treatment,  and  provided,  further,  that 
there  is  reliable  evidence  to  show  the  possession  of  resources 
which  will  enable  the  women  in  question  to  keep  their  engage- 
ment to  refrain  from  plying  their  vocation  for  the  time  being. 
Women  are  also  at  times  released  from  the  hospital  on  condi- 
tion that  they  report  at  intervals  for  further  treatment; 
should  this  understanding  be  violated  they  are  once  more 
interned. 

Clandestine  and  occasional  prostitutes  if  found  diseased 
on  being  arrested  are  somewhat  differently  managed.  If 
without  resources  they  are  sent  to  the  hospital;  but  the  bureau 
chief  may,  in  his  discretion,  permit  them  to  remain  at  large 
on  condition  that  they  place  themselves  in  charge  of  a  com- 
petent physician.  It  is,  however,  admitted  that  pledges, 
whether  given  by  clandestine  or  registered  women,  are  not 
to  be  relied  on. 

At  both  hospital  and  police  headquarters  in  Berlin  con- 
scientious and  intelligent  efforts  have  been  made  to  provide 
satisfactory  arrangements.  Registered  and  non-registered 
women  are  scrupulously  separated  at  every  stage,  on  the 
ground  that  the  latter  group  may  contain  young,  innocent  or, 
at  least,  not  yet  hardened  persons,  who  should  not  be  further 
contaminated  by  the  carelessness  of  the  State.  Premises 
not  adapted  to  this  end  have  therefore  been  extensively 
remodelled.  The  rooms  utilized  for  the  medical  examinations 
at  the  police  headquarters  are  light  and  equipped  with  a 


228  PUBLIC  HEALTH  MEASURES 

modern  examining  chair,  hot  and  cold  water,  and  electric 
light;  the  microscopic  room  has  the  necessary  equipment 
for  clean  and  accurate  work.  The  hospital,  though  old  and 
small,  has  been  latterly  renovated  and  its  staff  reorganized. 
The  present  medical  chief  of  police  division  in  charge  of 
venereal  disease  is  a  specialist  of  distinction,  who  has  made 
important  contributions  to  the  literature  of  the  subject  on 
both  medical  and  sociological  sides.  The  division  possesses 
an  excellent  laboratory  manned  with  trained  assistants; 
and  it  is  properly  equipped  with  microscopes,  culture  ovens, 
animals  for  experimental  purposes,  etc.  Patients  are 
examined  separately  in  a  clean,  well-lighted  room,  containing 
all  necessary  paraphernalia.  Women  at  different  stages 
of  demoralization — registered,  non-registered,  first  offenders 
— are  scrupulously  kept  apart;  clean  and  orderly  as  the 
women  are  in  appearance,  there  is  nothing  in  their  demeanor 
or  surroundings  to  suggest  prison  confinement." 

"  The  quality  of  the  examination  varies  widely.  At  Berlin, 
typical  of  the  four  best,  clinical  inspection  is  made  of  the 
mouth,  hands,  feet  and  other  external  surfaces;  the  genitalia 
are  invariably  explored  with  the  speculum;  microscopic 
examinations  for  gonococci  are  made  fortnightly,  or  oftener 
in  suspicious  cases.  The  magnitude  of  the  work  may  be 
roughly  indicated  as  follows :  On  the  basis  of  3500  inscribed 
women,  each  examined  twice  weekly,  28,000  clinical  examina- 
tions would  be  made  monthly — 3500  by  each  of  the  eight 
physicians.  As  a  matter  of  fact  the  figures  are  smaller, 
since  biweekly  examinations  are  required  only  of  women 
under  twenty-four.  It  would  be  nearer  the  truth  to  estimate 
that  each  physician  makes  from  1500  to  2000  clinical  exami- 
nations monthly.  In  August,  1911,  each  of  the  four  assist- 
ants made  2646  microscopic  examinations  for  gonococci,  an 
average  of  98  for  each  working  day.  It  is  estimated  that, 
on  the  average,  three  minutes  are  available  for  the  examina- 
tion; but  as  this  takes  no  account  of  time  lost,  the  actual 
duration  of  the  operation  is  much  less.  Women  sent  to  the 
hospital  are  discharged  only  after  three  successive  negative 
findings,  followed  by  an  examination  at  police  headquarters 
confirming  this  result." 


THE  CONTROL  OF   VENEREAL  DISEASES  229 

This  may  be  taken  as  an  example  of  medical  inspection 
and  regulation  at  its  best  in  Europe,  It  is  noteworthy,  how- 
ever, that  no  mention  is  made  of  the  Wassermann  reaction. 
If  this  is  not  performed,  obviously  the  greater  number  of 
cases  elude  detection,  even  with  such  a  well-conducted 
system  of  regulation.  Moreover,  the  time  allotted  to  the 
examination  of  each  patient  is  insufficient. 

2.  Not  all  of  even  the  registered  prostitutes  are  examined. 
Many  absent  themselves.  Thus:  "In  Stockholm  Moller 
found  that  of  857  controlled  women  286  were  missing  after 
one  month,  109  more  after  two  months,  100  more  after  three, 
76  more  after  four;  at  the  close  of  the  fifteenth  month  5 
per  cent,  were  left." 

"A  cursory  inspection  of  police  records  at  Bremen  showed 
me  that  with  few  exceptions  a  woman  was  rarely  on  the  rolls 
longer  than  a  few  months." 

"  Of  629  women  newly  inscribed  in  Breslau  during  the  year 
1886,  147  dropped  out  in  the  first  year,  94  in  the  second  and 
80  in  the  third." 

"In  addition  visits  are  frequently  missed,  so  that  those 
who  remained  on  the  rolls  are  examined  less  frequently 
than  the  regulations  require." 

3.  Only  a  few  of  those  actually  found  to  be  diseased  are 
withdrawn.  "  The  examining  physicians  realize  the  slipshod 
nature  of  their  work.  A  suspicious  secretion  having  been 
noted  by  a  bystander  in  the  case  of  a  woman  pronounced 
well,  the  physician  was  asked  how  he  knew.  He  shrugged 
his  shoulders;  I  don't  know,  but  there  is  no  way  to  tell.  If 
we  kept  cases  like  that  we'd  keep  over  half.  We  can't  keep 
them — we  haven't  space — though  we  aren't  sure  that  they 
are  well." 

"On  the  occasion  of  my  visit  to  St.  Lazarre  170  venereal 
women  were  confined  there,  and  I  was  informed  by  the  chief 
clerk  that  this  was  a  fair  average;  these  are  the  scapegoats 
for  the  venereal  disease  in  circulation  among  the  prostitutes 
of  the  French  capital.  Assuredly  the  temporary  withdrawal 
of  170  infected  women  from  the  thousands  with  whom  Paris 
teems  is  utterly  without  influence  in  the  long  run,  more 
especially  as  these   women   are   themselves  turned   adrift 


230  PUBLIC  HEALTH  MEASURES 

before  their  infectiousness  has  passed.  Regulations  of  this 
type  have  less  effect  in  reducing  disease  than  a  rainy  night, 
or  a  spurt  of  police  activity." 

4.  Even  if  detected  and  detained,  prostitutes  are  not 
detained  long  enough  to  render  them  non-effective. 

In  regard  to  the  above  criticism  we  find  among  others 
the  following :  "  Dr.  Commenge,  head  of  the  Paris  Bureau, 
reported  to  the  Brussels  conference  that  in  the  two  decades 
between  1877  and  1897,  15,095  syphilitic  prostitutes  were 
confined  in  St.  Lazarre,  an  ayerage  of  thirty  days  each.  In 
Vienna  between  1893  and  1896,  cases  of  gonorrhea  were 
detained  from  eighteen  to  twenty-one  days  and  cases  of 
syphilis  from  twenty-one  to  twenty-seven  days.  The  police 
bacteriologist  of  Budapest  states:  'One  and  the  same  pros- 
titute might  come  into  the  hospital  repeatedly  for  the  same 
infection.  We  know  that  syphilis  lasts  for  years;  it  is 
undeniable  that  since  the  hospitals  are  crowded  and  the  beds 
therefore  insufficient  in  number,  prostitutes  are  obliged  to 
leave  before  they  are  cured;  syphilitics  are  kept  at  least 
three  weeks,  gonorrheics  at  least  two.'  " 

II.  Faults  which,  if  they  exist,  are  inherent  in  any  system 
of  regulation. 

1.  One  indictment  against  regulation  is  the  statement  that 
it  promotes  irregular  intercourse  because  of  a  widespread 
impression  that  it  is  safe.  Indeed,  if  the  regulation  is  ineffi- 
cient, as  has  practically  always  been  the  case,  that  venereal 
diseases  may  be  actually  increased  as  the  result  of  the  in- 
creased indulgence  following  this  false  impression  of  security. 
Thus  Flexner  says:  "The  complacent  attitude  toward 
indulgence  implied  in  the  mild  effort  made  by  the  State  to 
remove  or  reduce  its  dangers  indubitably  diminishes  internal 
inhibition  on  the  part  of  the  male.  Nothing  is  more  certain 
in  the  domain  of  effort  and  ethics  than  that  good  conduct  is 
largely  the  response  of  the  individual  to  the  expectation  of 
society.  Men  can  because  they  think  they  can.  Social 
stigma  is  a  most  powerful  deterrent;  social  assent  a  powerful 
stimulus.  Regulation  implies  the  absence  of  any  expectation 
of  male  self-restraint;  it  is  society's  tacit  assent  to  laxity. 
Nay,  more,  it  is  an  invitation  to  laxity  in  so  far  as  it  deprives 


THE  CONTROL  OF   VENEREAL  DISEASES  231 

dissipation  of  one  of  its  terrors,  for  the  existence  of  medical 
regulation  must  be  interpreted  as  employing  a  certain  degree 
of  efficacy  in  the  attainment  of  its  object.  There  can,  there- 
fore, be  no  question  that  State  regulation  of  vice  increases  the 
volume  of  irregular  intercourse,  and  the  number  of  those  who 
participate  in  it.  Certain  it  is  that  the  notion  that  male 
self-control  is  both  possible  and  wholesome  has  spread  pari 
passu  with  the  attack  on  regulation  and  with  the  elevation 
of  the  status  of  woman  that  invariably  accompanies  this 
movement. " 

2.  A  second  serious  objection  urged  against  reglementation 
is  that  minors  cannot  be  inscribed  and  regulated. 

"  Immoral  girls  still  in  their  minority  are  at  once  the  most 
attractive  and  the  most  dangerous  prostitutes;  ignorant  and 
reckless,  they  are  quickly  infected  and  their  infection  is 
distributed  to  a  larger  clientele.  How  many  infecting  foci 
escape  sanitary  control  by  the  exclusion  of  minors  a  few 
figures  will  make  clear.  Out  of  4341  cases  of  obviously  infec- 
tious syphilis  in  Viennese  prostitutes,  44.9  per  cent,  were 
between  fifteen  and  twenty  years  of  age,  38.1  per  cent,  between 
twenty-one  and  twenty-five. 

"  The  chief  physician  of  the  Vienna  police,  in  1908,  gave  a 
most  striking  proof  of  the  collapse  brought  about  by  excepting 
minors  for  regulation,  as  he  admitted  must  be  the  case:  in 
1900,  329  prostitutes  were  newly  enrolled,  303  of  whom  (92.2 
per  cent.)  were  between  fifteen  and  twenty-five  years  of  age; 
in  that  year  2686  cases  of  venereal  disease  were  detected 
among  inscribed  women.  In  1907,  83  prostitutes  were  newly 
enrolled,  of  whom  63  were  between  fifteen  and  twenty-five 
years  old;  426  venereal  cases  were  discovered  in  that  year. 
In  the  same  measure  as  the  enrolment  of  minors  declines  the 
total  amount  of  disease  discovered  declines  correspondingly." 

3.  A  third  serious  objection  brought  against  regulation  is 
that  under  any  system  the  registered  prostitutes  form  only  a 
small  portion  of  the  total  army  of  prostitution,  Clandestines 
are  not  affected.  Flexner  says  (page  243):  "I  have 
repeatedly  pointed  out  that  on  any  rational  definition  of 
prostitution  the  total  army  of  prostitutes  is  many  times  as 
large  as  the  registered  portion.    Most  of  these  women  ply 


232  PUBLIC  HEALTH  MEASURES 

their  business  unhindered.  Having  had  precisely  the  same 
history  as  the  registered  women,  and  conducting  their  affairs 
with  similar  promiscuity,  disease  is  of  course  equally  rife 
among  them.  Yet  so  long  as  they  conduct  themselves  with 
discretion  they  are  free  from  public  interference;  in  towns 
where  compulsory  enrolment  takes  place  (e.  g.,  Berlin  and 
Hamburg)  they  must  be  thrice  warned  before  they  are 
arrested  and  compelled  to  submit  to  medical  examination 
with  a  chance  of  compulsory  registration;  elsewhere,  as  at 
Bremen,  Munich,  Stuttgart,  etc.,  they  are,  if  arrested  for 
disorder,  medically  inspected,  but  are  in  no  event  compelled 
by  forced  inscription  to  submit  to  regular  examination  after- 
ward. Thus  only  the  disorderly  clandestine  or  non-inscribed 
woman  is  ever  anywhere  inspected  at  'all.  The  cautious 
street-walker  and  fashionable  and  showy  women  who  in 
Berlin  frequent  the  Palais  de  Danse  are  never  inscribed, 
despite  their  notorious  character.  Women  of  the  latter  type 
are,  in  fact,  nowhere  enrolled,  yet  they  do  a  large  business, 
dangerous  not  so  much  on  account  of  syphilis,  which  is  with 
them  long  since  a  matter  of  the  past,  as  on  account  of  gonor- 
rhea from  which  they  are  chronic  sufferers.  How  much 
disease  regulation  in  one  way  or  another  thus  permits  to  go 
untouched  among  the  non-inscribed  is  made  clear  by  the 
amount  of  disease  detected  among  the  small  part  of  clandes- 
tine or  non-registered  prostitution  that  the  police  lay  hold  of. 
A  single  clinical  examination  of  each  of  the  12,825  non-inscribed 
women  arrested  in  Berlin  in  five  successive  years  (1903-1907 
inclusive)  showed  17  per  cent,  venereally  diseased;  of  1514 
arrested  in  1909  and  1910,  421  were  diseased.  At  Cologne  the 
percentage  is  much  higher;  660  non-inscribed  women  were 
arrested  in  1906,  178  were  infected;  1626  were  arrested  in 
1911,  304  were  infected.  At  Vienna  1319  such  arrests  were 
made  in  1910;  222  cases  of  infection  were  discovered  among 
them.  It  must  be  emphasized  that  the  police  surgeons  get 
hold  of  these  women,  not  because  they  are  diseased,  but 
because  they  are  disorderly.  Had  they  remained  sober  and 
quiet,  regulation  would  have  permitted  them  to  continue 
undisturbed  in  the  work  of  spreading  infection,  precisely  as 
it  does  not  touch  the  thousands  of  others,  who,  however 


THE  CONTROL  OF   VENEREAL  DISEASES  233 

diseased,  are  careful  to  keep  the  peace.  The  amount  of 
disease  thus  surprised  is  interesting  as  a  symptom  of  the 
vastly  larger  amount  that  wholly  eludes  observation;  and, 
finally,  the  disease  thus  detected  is — like  the  disease  occurring 
among  inscribed  women — but  a  part  of  that  actually  existing 
among  those  examined;  and  like  all  the  rest,  is  readmitted 
to  circulation  while  still  infectious  after  an  inadequate  period 
of  detention." 

4.  A  fourth  objection  against  regulation  is  that  only  the 
female  prostitute  is  regulated.  Under  all  systems  that  have 
been  tried  the  male  offender  escapes  scot-free. 

Thus  Flexner  says:  "A  final  absurdity  remains  to  be 
pointed  out.  What  can  it  avail  to  incarcerate  for  brief 
periods  a  few  unhappy  women  if  meanwhile  the  manufacture 
of  fresh  foci  of  infection  proceeds  unhampered?  So  long  as 
regulation  completely  omits  men,  new  sources  of  infection  are 
produced  far  more  rapidly  than  by  any  known  method  they 
can  be  eradicated.  A  vicious  circle  exists.  Men  infect  the 
beginners — themselves  at  the  time  out  of  reach — who  in  their 
turn  infect  other  men.  I  pointed  out  in  the  opening  chapter 
that  prostitution  is  a  concept  involving  two  persons.  Logic 
and  justice  alike  require  that  both  parties  be  considered  as 
equal  partners  in  the  act;  and  in  no  respect  is  it  more  com- 
pletely impossible  to  omit  either  of  the  two  essential  factors 
from  the  reckoning  than  in  the  matter  of  disease.  Society 
has  chosen  to  overlook  the  man,  but  Nature  has  righted  the 
balance  by  impartially  distributing  disease  and  suffering; 
nor  will  she  permit  herself  to  be  outwitted  by  any  one-sided 
scheme,  even  though  it  be  far  more  extensive  and  efficient 
than  regulation  has  thus  far  anywhere  been." 

5.  Another  objection  often  urged  against  regulation  is  that 
it  is  an  unwarranted  invasion  of  personal  libferty.  By  what 
right  do  we  subject  women  to  a  compulsory  physical  examina- 
tion, and  what  guarantee  have  we  that  innocent  women  and 
girls  may  not  by  some  combination  of  circumstances  be 
subjected  to  this  indignity? 

6.  A  sixth  and  most  serious  objection  is  that  it  is  claimed 
that  regulation  makes  the  State  a  partner  in  immorality. 
From  the  moral  point  of  view  the  city  simply  becomes  a  high 


234  PUBLIC  HEALTH  MEASURES 

class  procurer.  This  objection  is  most  difficult  to  answer, 
and  is  the  main  reason  why  regulation  has  seldom  been 
adopted  in  this  country. 

There  are  answers  to  this  objection,  but  they  fail  to  satisfy 
the  moral  sense  of  the  community.  Every  objection  that 
has  been  raised  can  be  answered.  To  those  who  object  that 
regulation  discriminates  against  the  woman  and  allows  the 
male  to  go  free,  it  may  be  answered  that  the  man  who  goes  to 
a  bordel  is  not  a  prostitute  any  more  than  a  man  who  buys  a 
ring  at  a  jeweller's  shop  is  a  jeweller.  The  essence  of  prosti- 
tution is  the  making  a  business  of  the  traffic,  and  this  the 
woman  does  and  the  man  does  not.  Of  the  total  number  who 
visit  these  places  only  a  certain  percentage  are  habitues,  and 
the  remainder  are  occasional  visitors  or  perhaps  never  go 
more  than  once  or  twice. 

There  is  no  question  of  a  double  standard  of  morals.  The 
man  who  purchases  may  be  no  better  than  the  woman  who 
sells  so  far  as  this  offence  is  concerned.  But  the  man  sins 
occasionally,  the  woman  sins  habitually  as  a  matter  of 
business.  In  regulating  prostitutes  and  not  the  men  there 
is  no  intention  to  discriminate  against  the  woman,  but  she  is 
regulated  because  she  has  a  place  of  business,  and  it  is  possible 
to  reach  her  while  it  is  impossible  to  reach  the  man.  When  we 
attempt  to  regulate  the  liquor  business  we  regulate  the 
saloon,  but  we  do  not  attempt  to  regulate  the  individual 
purchaser.  The  moral  side  of  the  question  is  not  considered, 
but  we  can  reach  the  seller  while  it  is  difficult  or  impossible 
to  reach  the  buyer. 

The  faults  that  have  been  found  with  the  medical  service  of 
inspection  have  undeniably  existed.  But  they  are  not  neces- 
sary. Theoretically  it  would  be  easy  to  describe  a  satis- 
factory and  efficient  method  of  medical  inspection.  It  would, 
however,  be  very  costly,  and  it  is  doubtful  whether  the 
community  would  bear  the  expense  of  a  properly  conducted 
inspection. 

Discussion  might  be  endless,  but  it  is  stale  and  unprofitable. 
Systems  of  regulation  have  not  worked  in  the  past,  and  while 
it  cannot  be  denied  that  this  is  no  proof  that  they  cannot  be 
made  to  work,  it  constitutes  weighty  evidence  in  favor  of  the 


THE  CONTROL  OF   VENEREAL  DISEASES         235 

belief  that  with  our  defective  organization  and  human  frailties 
they  will  not  work  in  the  future  either.  Add  to  this  the 
undoubted  fact  that  the  moral  sense  of  the  community  is 
opposed  to  regulation,  and  the  situation  becomes  such  that 
the  sanitary  officer  might  as  well  abandon  any  intention  to 
establish  such  a  system,  even  though  he  personally  may 
believe  in  it. 

Treatment.- — If  it  is  true  that  suppression  will  fail  to 
entirely  suppress  prostitution,  then  even  though  this  method 
is  adopted  by  the  community  it  must  be  combined  with  a 
systematic  effort  to  treat  those  infected  if  the  prevalence  of 
venereal  diseases  is  to  be  appreciably  diminished.  If  in 
addition  it  be  granted  that  regulation  is  impossible  and 
sociological  reform  a  matter  of  gradual  evolution,  we  are 
logically  driven  to  accept  systematic  treatment  as  the  only 
method  left  to  the  community  to  reduce  the  number  of 
venereal  infections,  and  particularly  the  number  of  syphilitic 
infections  with  which  subject  this  work  deals. 

Moreover,  in  addition  to  being  the  only  method  available 
it  is  the  most  hopeful  method  for  several  reasons.  It  is  the 
one  method  upon  which  everyone,  whatever  their  moral 
beliefs,  can  agree,  for  the  morality  of  the  healing  of  the  sick  is 
above  suspicion,  and  no  one  will  challenge  the  morality  of 
the  attempt  to  treat  all  venereal  diseases.  From  the  sanitary 
point  of  view  the  treatment  of  the  infected  is  perhaps  the  most 
efficacious  single  method  that  can  be  applied.  It  is  obvious 
that  if  all  infected  individuals  are  rendered  incapable  of 
transmitting  their  infection  the  disease  will  disappear. 

To  accomplish  this  end,  systematic  treatment  is  necessary. 
Syphilis  has  been  treated  for  hundreds  of  years  without 
accomplishing  anything  from  the  sanitary  point  of  view,  but 
the  disease  has  been  treated  spasmodically  and  inefficiently. 
The  individual  patient  has  or  has  not  received  proper  treat- 
ment— and  usually  has  not — because  he  has  been  too  ignorant 
or  too  poor  to  pursue  a  proper  course  of  treatment.  We 
cannot  rely  on  the  efficacy  of  treatment  given  under  these 
circumstances  and  cannot  expect  that  any  appreciable  reduc- 
tion in  the  number  of  new  infections  will  result  from  treatment 
so  pursued.    It  is  certain  therefore  that  if  anything  at  all  is 


236  PUBLIC  HEALTH  MEASURES 

to  be  done  a  collective  effort  must  be  made  by  the  com- 
munity to  accomplish  the  effective  treatment  of  venereal 
diseases,  particularly  syphilis.  We  are  in  a  better  position 
to  do  this  than  ever  before,  because  our  knowledge  of  the 
etiology  of  syphilis  is  now  sufficiently  complete  for  sanitary 
purposes;  we  have  at  our  command  efficient  methods  of 
detecting  the  disease,  namely,  the  Wassermann  reaction  and 
more  especially  the  examination  of  the  primary  lesion  for 
treponemata,  whereby  the  diagnosis  may  be  established  at  a 
time  when  the  disease  is  curable;  and  finally  we  have  two 
remedies  at  our  command  that  are  specifics,  salvarsan  and 
mercury. 

Since  we  cannot  rely  upon  the  individualistic  methods  of 
the  past  for  sanitary  results  it  becomes  necessary  to  discuss 
the  methods  that  the  community  may  take  in  securing  effec- 
tive treatment  of  those  infected.  Before  the  community  can 
insist  upon  the  efficient  treatment  of  all  syphilitics  it  becomes 
necessary  to  know  who  are  the  syphilitics,  how  many  of  them 
there  are,  where  they  are  located  and  to  provide  sufficient 
facilities  for  treatment.  This  naturally  leads  to  the  discussion 
of  notification. 

Notification. — The  best  opinion  of  today  holds  that  notifi- 
cation is  an  impracticable  measure.  Notification  has  been 
tried  in  the  past  and  has  failed.  Thus  to  quote  only  a  single 
instance,  Christiania,  a  city  of  slightly  over  250,000  inhabi- 
tants, tried  this  measure.  According  to  the  Health  Inspector 
Dr.  Ustvedt,^  during  the  year  1915  its  medical  practitioners 
and  infirmaries  notified  2424  new  cases  of  venereal  disease, 
of  which  gonorrhea  accounted  for  1549,  acquired  syphilis 
585,  chancroid  243  and  congenital  syphilis  47.  During  the 
last  ten  years  the  annual  notifications  have  averaged  0.84 
per  cent,  of  the  population,  and  in  1915  the  percentage  was 
0.96.  From  this  it  may  be  seen  what  a  farce  notification  may 
become.  In  the  United  States  army,  in  1915,  the  venereal 
rate  was  8.36  per  cent,  for  enlisted  men  in  the  United  States, 
the  lowest  rate  obtained  for  many  years.  The  admission  rate 
for  syphilis  alone  was  17.24  per  thousand,  also  the  lowest 
figure  in  many  years.  It  is  obvious  that  in  Christiania  the 
law  was  ignored. 


THE  CONTROL  OF   VENEREAL  DISEASES  237 

The  British  Royal  Commission  did  not  favor  notification. 
The  British  Medical  Association  appointed  a  committee, 
consisting  of  the  chairmen  of  all  standing  committees,  to 
consider  what  should  be  the  attitude  of  that  body  in  regard 
to  notification.  They  arrived  unanimously  at  the  conclusion 
that  such  a  system  would  be  unfortunate.  The  main  objec- 
tions found  by  the  committee  were  that  such  a  law  would 
lead  to  the  concealment  of  venereal  diseases,  and  that  even 
if  notification  were  made  it  would  not  help  any  in  the  treat- 
ment of  such  diseases.  The  British  Medical  Association  is 
of  the  opinion  that  there  are  two  indispensable  preliminary 
steps  to  such  a  law.  (1)  Facilities  should  be  provided  by  the 
community  so  that  the  suffering  individuals  may  be  assured 
of  proper  treatment,  regardless  of  their  financial  condition. 
(2)  That  charlatans  should  be  put  out  of  business  by  directing 
heavy  penalties  against  the  advertising  of  quack  nostrums 
and  the  attempt  to  treat  venereal  diseases  by  unqualified  or 
incompetent  persons. 

That  all  in  England  are  not  satisfied  with  this  conclusion  is 
shown  by  the  fact  that  a  letter  was  issued,  signed  by  a  large 
number  of  women  of  distinction,  and  calling  on  the  wives 
and  mothers  of  the  Empire  to  demand  the  compulsory  notifi- 
cation and  treatment  of  venereal  diseases.  These  women 
were  dissatisfied  with  the  conclusions  of  the  Royal  Commis- 
sion and  find  it  almost  incredible  that  men  and  women  known 
to  be  infectious  should  be  at  liberty  to  spread  the  contagion 
when  and  where  they  will.  The  letter  states  that  "the 
obvious  remedies  for  every  contagious  disease  are  notifica- 
tion and  compulsory  treatment,  and  other  dangerous  and 
contagious  diseases  are  thus  treated." 

The  National  Council  for  Combating  Venereal  Diseases 
issued  the  following  answer:  "Compulsory  notification  is 
obviously  only  one  of  the  many  means  to  an  end,  namely, 
the  suppression  of  these  diseases,  and  a  more  comprehensive 
scheme  is  necessary  if  that  end  is  to  be  attained.  To  be 
effective  the  scheme  must  in  our  judgment  include  as  the 
first  and  most  necessary  measures:  (1)  The  provision  in 
every  area  of  adequate  facilities  for  prompt  diagnosis  and 
efficient  treatment,   free   of   charge.      (2)  The   prohibition 


238  PUBLIC  HEALTH  MEASURES 

of  quack  treatment.  (3)  Granting  of  privilege  to  any 
communication  made  in  good  faith  by  a  medical  man  in 
order  to  prevent  the  spread  of  infection.  Notification  must 
be  futile  unless  accompanied  by  police  measures  for  enforc- 
ing treatment  which  could  not  be  given  until  full  facilities 
has  been  made  available  to  all  classes.  When  these  facilities 
have  been  provided,  the  question  of  compulsion  can  be 
considered."^ 

Opinion  is  very  similar  in  this  country.  Thus  in  a  dis- 
cussion on  the  subject^  Dr.  Emerson,  of  New  York,  objected 
to  reporting  on  the  ground  that  it  was  useless.  He  is  reported 
to  have  said:  "What  are  you  going  to  do?  Are  you  going  to 
placard  the  house?  Are  you  going  to  quarantine  the  indi- 
vidual? What  are  you  going  to  do  with  your  patient  when 
you  have  got  him  reported?  So  far  as  I  can  see  this  reporting 
of  venereal  disease  amounts  simply  to  stating  that  we  know 
how  many  there  are,  don't  know  where  they  are,  can't  keep 
them  located,  and  can't  deny  them  free  movement  through 
the  community." 

Dr.  Hugh  Cabot,  of  Boston,  has  the  following  to  say  with 
regard  to  notification:'^ 

"At  the  outset  of  any  attempt  to  estimate  the  value  of 
reporting  as  a  public  health  measure  it  is  necessary  to  dis- 
tinguish between  true  reporting  and  false  reporting.  True 
reporting  requires  that  the  case  be  notified  to  the  health 
authorities  by  name  and  address  precisely  as  are  other  cases 
of  contagious  diseases,  including  tuberculosis.  False  report- 
ing is  reporting  by  number  or  by  some  quasi-secret  method 
and  is  evidently  an  attempt  to  deal  with  these  conditions  in 
a  manner  not  thought  applicable  to  other  forms  of  contagious 
disease.  On  the  question  of  the  value  of  reporting  there  are 
three  types  of  opinion: 

"1.  The  opinion  of  the  public  health  officer. 

"2.  The  opinion  of  the  practising  physician. 

"3.  The  opinion  of  the  enthusiastic  layman  (generally 
woman) . 

"1.  Broadly  speaking,  the  opinion  of  the  public  health 
officer  has  generally  been  in  favor  of  reporting.  In  June, 
1913,  the  annual  conference  of  State  and  territorial  public 


THE  CONTROL  OF   VENEREAL  DISEASES  239 

health  authorities  with  the  United  States  Pubhc  Health 
Service  approved  a  model  law  for  morbidity  reports  pre- 
pared by  a  committee  of  that  conference.  This  law  provided 
for  the  reporting  of  venereal  disease,  including  gonococcus 
infection  and  syphilis,  but  in  the  section  specifying  how  the 
reportmg  should  be  done  there  is  inserted,  'Provided  that 
in  the  reports  of  cases  of  venereal  disease  the  name  and 
address  of  the  patient  need  not  be  given.'  It  thus  appears 
that  though,  as  a  group,  they  favor  reportability  they  recog- 
nize the  difficulties  that  stand  in  its  way  are  prepared  to 
temporize  with  half-way  measures.  Such  measures  can  only 
be  justified  on  the  ground  that  they  represent  a  step  toward 
true  reporting  and  are  intended  to  get  public  opinion  accus- 
tomed to  the  appearance  of  these  diseases  in  the  weekly  or 
monthly  reports  and  later  to  support  the  attempt  to  make 
these  diseases  truly  reportable.  To  this  it  may  properly 
be  objected  that  reporting  by  number  not  only  has  no  statis- 
tical value  but  it  is  positively  misleading.  There  is  no  method 
of  identification  of  the  cases,  and  while  it  is  to  be  presumed 
that  a  large  number  of  cases  will  not  be  reported  at  all,  it 
is  equally  to  be  presumed  that  the  same  patients  will  be 
reported  upon  a  variety  of  occasions  by  different  physicians 
or  institutions,  this  conclusion  being  justified  by  our  knowl- 
edge of  the  extremely  peripatetic  habits  of  these  individuals. 
"2.  The  opinion  of  the  practising  physician  and  particu- 
larly of  those  physicians  who  deal  with  s^^hilis  on  a  large 
scale  has  been  almost  unanimously  opposed  to  reporting. 
They  reason  that  if  physicians  are  required  to  report  these 
patients  by  name  they  will  in  a  short  time,  if  they  are  honest, 
have  no  patients  to  report.  This  will  have  the  exceedingly 
undesirable  effect  of  throwing  this  disease  into  the  care  of 
the  dishonest  physician,  the  quack,  and  the  charlatan,  and, 
far  from  acting  as  a  method  of  controlling  the  diseases,  it 
will  not  only  make  it  less  controllable  but  more  sever.'  in 
its  manifestations.  They  further  reason  that  if  the  reports 
are  really  private  if  made  by  name,  they  are  of  no  practicable 
value  to  the  health  officer  since  by  the  very  nature  of  his 
agreement  with  the  patient  he  is  stopped  from  using  the 
information  for  the  benefit  of  the  public  health,  and  finally 


240  PUBLIC  HEALTH  MEASURES 

they  point  out  that  if  the  report  is  made  only  by  number, 
no  important  statistical  evidence  will  be  obtained,  dupli- 
cation will  certainly  occur,  and  no  benefit  will  result.  That 
the  latter  argument  is  cogent  seems  to  be  borne  out  by  the 
experience  of  New  York  City  where  physicians  and  institu- 
tions have  been  urged  to  report  by  number.  From  the 
reports  of  the  months  of  November  and  December,  1915, 
and  January,  1916,  it  appears  that  the  number  of  cases  of 
syphilis  reported  in  a  week  varies  from  564  to  195,  and  sur- 
prisingly enough,  the  number  of  cases  of  syphilis  reported 
is  almost  double  the  number  of  cases  of  gonococcus  infection 
during  the  same  period,  4114  as  against  2379.  That  there 
are  doubtless  a  variety  of  perfectly  good  reasons ,  for  this 
extraordinary  result  may  be  admitted  but  it  collides  so 
violently  with  the  facts  and  with  common  sense  that  it  is 
impossible  to  regard  such  figures  as  having  scientific  or  even 
social  value. 

"3.  While  it  may  be  doubted  whether  it  is  worth  while 
to  introduce  into  this  discussion  lay  opinion,  it  should  be 
borne  in  mind  that  lay  opinion  has  been  an  exceedingly 
important  factor  in  placing  legislation  about  these  matters 
upon  the  statute  books,  and  though  we  may  properly  believe 
that  such  opinion  is  rarely  based  upon  a  knowledge  of  facts 
that  would  entitle  the  individual  to  any  opinion  at  all,  we 
cannot  disregard  it  as  a  factor  in  social  activity.  Average 
lay  opinion  appears  to  take  the  view  that  the  prevalence  of 
syphilis  in  the  community  is  a  shocking  condition  largely 
aided  and  abetted  by  the  medical  profession  in  their  attempt 
to  shield  their  patients.  There  has  been  much  agitation  from 
women's  clubs  and  associations,  and  particularly  from  the 
more  boisterous  advocates  of  women's  suffrage,  most  of 
whom  regard  the  problem  as  a  simple  one,  and  the  remedy 
to  lie  in  universal  suffrage.  Very  generally  lay  opinion  has 
supported  suggestions  to  make  this  disease  reportable,  and 
much  existing  legislation  has  come  either  from  this  source 
or  from  the  advocacy  of  the  public  health  officer  with  an 
amiable  disregard  of  the  gross  improbability  that  such  legis- 
lation will  serve  any  useful  purpose  and  the  almost  absolute 
certainty  that  it  will  only  encumber  the  statute  books  with 


THE  CONTROL  OF   VENEREAL  DISEASES         241 

laws  that  are  unenforcible  and  serve  no  purpose  other  than 
to  bring  the  law  into  well-merited  contempt. 

"  After  a  pretty  thorough  study  of  this  question  of  report- 
ing, I  cannot  avoid  the  opinion  that  it  has  been  worthless 
as  a  method  of  assisting  in  the  control  of  this  particular 
variety  of  contagious  disease.  Public  opinion  has  stamped 
syphilis  as  a  shameful  disease,  as  we  all  know  without  suffi- 
cient justification,  and  has  therefore  driven  these  unfortunate 
persons  into  hiding.  From  this  hiding  they  have  begun  to 
emerge,  and  are  more  and  more  seeking  the  advice  of  well- 
trained  and  honest  physicians.  From  these  physicians  they 
expect  and  will  receive  protection  since  they  have  entered 
into  an  implied  contract  and  one  which  cannot  properly 
be  disregarded.  To  the  extent  that  the  treatment  of  syphilis 
is  in  the  hands  of  such  practitioners,  to  exactly  that  extent 
the  disease  cannot  be  made  reportable.  Such  portion  of  the 
cases  as  are  in  the  hands  of  dishonest  practitioners  and 
charlatans  are  inaccessible  to  the  law,  since  these  people  will 
beat  not  only  the  law,  but  the  patient.  Any  law  that  is  to 
achieve  success  must  be  of  practical  benefit  to  the  patient, 
a  fact  that  must  have  been  commonly  overlooked  by  the 
advocates  of  reportability.  As  generally  proposed  it  is  an 
attempt  to  protect  the  community  against  a  contagious  indi- 
vidual without  any  corresponding  benefit  to  him  and  with 
a  very  large  probability  that  it  will  do  him  considerable 
damage.  Until  such  time  as  we  are  prepared  to  enact 
legislation  which  will  be  of  at  least  as  much  benefit  to  the 
syphilitic  as  to  the  community,  we  may  as  well  dismiss  this 
kind  of  legislation  as  a  factor  in  improving  the  situation." 

I  have  quoted  these  criticisms  of  notification  at  length, 
not  because  I  agree  with  the  conclusions  drawn,  but  because 
they  contain  real  objections  which  must  be  met,  and  met 
successfully  before  notification  can  be  enforced.  I  think 
that  the  lay  opinion  that  the  prevalence  of  syphilis  in  the 
community  is  a  shocking  condition  and  that  something 
must  be  done  about  it  is  fully  justified  by  the  facts,  and  as 
it  is  upon  lay  opinion  that  we  must  depend  for  the  enforce- 
ment of  any  law,  this  is  to  be  considered  as  the  hopeful  sign 
that  notification  can  be  made  to  work  providing  the  objec- 
16 


242  PUBLIC  HEALTH  MEASURES 

tions  already  referred  to  are  done  away  with.  It  serves  no 
purpose  to  point  out  that  all  cases  will  not  be  reported  and 
that  the  statistics  so  secured  are  of  questionable  value.  For 
the  matter  of  that,  birth  registration  cannot  be  regarded 
as  a  distinguished  success  in  this  country,  and  yet  no  one 
would  argue  that  we  should  not  attempt  to  enforce  this  law. 
The  betrayal  of  the  confidence  of  the  patient  is  simply  a 
bugbear.  We  betray  this  confidence  every  day  when  we 
report  infectious  diseases,  often  to  the  great  inconvenience 
of  the  patient  who  must  be  quarantined.  No  physician 
would  hesitate  to  report  smallpox  or  cholera  or  leprosy 
though  this  betrays  the  patient's  confidence  quite  as  much 
as  if  the  disease  were  syphilis.  If  the  law  compelling  notifi- 
cation of  venereal  diseases  were  passed,  and  its  enforcement 
demanded  by  lay  opinion,  the  physician  will  be  under  a  moral 
compulsion  to  obey  the  law.  The  community  is  also  our 
patient  and  besides  issues  our  license  to  practice,  and  we 
should  think  quite  as  much  about  violating  the  confidence 
of  the  community  as  about  the  confidence  of  the  individual 
patient. 

The  real  objections  that  must  be  met  are  that  notification 
will  turn  these  cases  over  to  quacks  and  charlatans,  that  it 
must  be  made  a  benefit  to  the  patient  as  well  as  to  the 
community,  and  that  ample  facilities  for  treatment  for  all 
classes  of  patients  must  be  first  provided. 

Quacks  and  Quack  Reviedies.-^ At  the  present  time  a  very 
large  number  of  men  suffering  from  venereal  disease  go  to 
quacks,  or  after  a  home-made  diagnosis  take  some  proprietary 
remedy.  To  their  disgrace  a  large  number  of  daily  papers 
are  full  of  the  advertisements  of  such  persons  and  remedies, 
although  journals  of  the  better  class  have  for  some  time 
closed  their  pages  to  such  advertising.  Under  existing 
circumstances  there  can  be  little  doubt  that  if  venereal 
diseases  were  made  reportable,  the  volume  of  this  traffic 
would  be  very  greatly  increased  to  the  detriment  of  the 
patient  and  of  public  health.  But  we  do  not  conclude  from 
this  fact  that  we  should  abandon  the  ideal  of  notification, 
for  as  we  have  seen,  the  only  hope  left  to  society  for  the  con- 
trol of  these  diseases  lies  in  effective  treatment  of  all  cases, 


THE  CONTROL  OF   VENEREAL  DISEASES  243 

and  this  can  only  be  secured  by  notification.  On  the  contrary, 
the  conclusion  is  fairly  obvious  that  the  community  should 
eliminate  the  quack  and  the  nostrum  sold  for  the  treatment 
of  venereal  disease.  While  this  is  a  matter  of  considerable 
difficulty  it  is  by  no  means  impossible.  The  existing  laws 
are  sufficient  in  most  communities  to  remedy  this  matter 
if  they  were  only  enforced,  and  where  they  are  insufficient, 
they  should  be  changed.*  The  times  are  favorable  for  such 
an  advance.  Many  communities  with  the  cooperation  of 
wide-awake  medical  societies  and  prosecuting  attorneys  have 
succeeded  in  compelling  their  quacks  to  close  their  doors, 
and  the  United  States  Government  has  shown  a  disposi- 
tion to  close  the  mails  to  any  remedy  that  can  be  shown  to  be 
fraudulent,  and  the  better  class  of  journals  no  longer  accept 
their  advertising.  If  medical  men  and  societies  will  only 
insist  on  the  enforcement  of  the  law  the  major  part  of 
quackery  will  disappear.  The  sanitary  officer  should  take  a 
leading  part  in  such  action.  Whenever  medical  men  assail 
quackery  they  always  fear  the  accusation  that  they  are 
persecuting  these  men  because  of  professional  jealousy. 
None  but  the  ignorant  will  bring  this  accusation,  but  if  the 
city  itself,  actuated  by  the  public  health  officials,  can  be 
brought  to  take  this  action,  even  the  ignorant  can  hardly 
believe  that  professional  jealousy  is  the  motive. 

As  for  the  quacks  that  cannot  be  reached  by  the  law,  the 
licensed  medical  men  who  disgrace  their  profession  by  adver- 
tising that  they  cure  or  treat  venereal  diseases,  the  life  of 
their  business  is  advertising.  An  effort  should  be  made  by 
medical  societies  and  all  whom  they  can  enlist  to  persuade 
the  daily  papers  to  refuse  this  type  of  advertising.  There  is 
already  a  campaign  for  clean  advertising,  and  reputable 
advertisers  are  learning  that  the  reputation  of  their  product 
sufi^ers  from  being  advertised  by  the  same  sheet  that  reeks 
with  "Specialists"  and  private  remedies.  City  ordinances 
should  prohibit  the  pasting  of  quack  notices  concerning  the 
treatment  of  these  diseases  in  public  places  and  in  saloons, 
and  wherever  possible  and  advisable  the  city  should  sub- 

*  See  Appendix  for  law  of  Western  Australia  and  Law  of  State  of  Missouri. 


244  PUBLIC  HEALTH  MEASURES 

stitute  for  these  notices  a  simple  statement  of  the  places 
which  the  city  affords  for  the  free  consultation  and  treatment 
of  these  diseases.  Quackery  is  not  so  profitable  or  so  easy 
as  was  formerly  the  case,  and  it  can  be  made  almost  impos- 
sible. Outside  of  a  desire  for  secrecy  and  a  hesitancy  about 
consulting  the  family  physician  for  such  ailments,  the  main 
source  of  revenue  of  the  quack  is  the  ignorant  man  who 
believes  the  statements  in  the  advertisements,  and  the 
deluded  mortal  who  believes  he  is  going  to  secure  a  cure  in  a 
shorter  time  and  for  less  expenditure  than  if  he  went  to  a 
qualified  physician.  When  proper  facilities  are  afforded 
the  poor  for  the  treatment  of  this  class  of  diseases,  one  of 
the  main  props  of  the  quack  will  have  been  removed.  They 
are  not  in  business  for  their  health,  and  they  will  not  be  able 
to  compete  with  the  free  clinics  maintained  by  the  city  or 
by  the  hospitals. 

How  may  notification  be  made  a  benefit  to  the  patient 
as  well  as  to  the  community?  It  appears  to  me  that  if  every 
patient  so  reported  is  assured  of  efficient  treatment  to 
relieve  his  condition,  that  he  will  be  most  distinctly  bene- 
fited, for  it  can  hardly  be  claimed  that  he  has  any  assurance 
of  such  treatment  under  the  present  system.  Let  us  suppose 
such  a  law  in  operation,  and  follow  its  results.  A  well-to-do 
patient  consults  his  family  physician  or  a  skilled  specialist. 
After  a  thorough  examination,  including  a  Wassermann 
reaction  which  is  performed  by  the  city  free  of  charge,  the 
physician  says:  "Mr.  Jones,  I  am  very  sorry  to  tell  you 
that  you  have  an  undoubted  chancre,  which,  as  you  know, 
is  the  initial  lesion  of  syphilis.  Now,  under  the  law  I  shall 
be  compelled  to  report  you  to  the  health  officer  as  having 
contracted  syphilis,  but  this  need  really  give  you  no  concern 
at  all.  The  health  officer  is  a  physician  who  is  no  more  dis- 
posed to  violate  your  confidence  than  I  am  myself.  All  he 
wants  in  the  matter  is  to  be  sure  that  all  contracting  this 
disease  will  receive  efficient  treatment;  and  if  you  will  agree 
to  submit  to  the  treatment  that  I  will  prescribe,  will  present 
yourself  at  certain  intervals  in  order  that  I  may  ascertain 
that  you  are  not  suffering  from  any  manifestation  of  the 
disease,  and  will  not  go  to  another  physician  without  giving 


THE  CONTROL  OF   VENEREAL  DISEASES  245 

me  due  warning,  I  will  inform  the  health  officer  that  this 
case  is  under  my  personal  supervision.  Under  these  circum- 
stances, if  I  had  not  told  you  of  the  necessity  for  reporting 
the  case,  you  would  probably  have  been  ignorant  of  the  fact, 
for  the  health  officer  never  interferes  so  long  as  he  is  satisfied 
that  patients  are  receiving  proper  treatment.  The  records 
are  kept  where  no  one  but  the  health  officer  and  his  qualified 
assistants  who  are  also  physicians  have  access  to  them. 
If,  however,  you  should  fail  to  present  yourself  for  observa- 
tion at  the  proper  intervals,  or  should  fail  to  take  the  treat- 
ment I  prescribe,  I  shall  be  compelled  to  report  this  fact, 
and  the  health  officer  might  then  take  such  measures  as  he 
thinks  best  to  ensure  that  you  receive  proper  treatment. 
You  are  of  course  at  perfect  liberty  to  consult  any  other 
physician  that  you  prefer,  and  the  only  reason  for  notifying 
me  is  in  order  that  I  may  be  relieved  of  the  responsibility 
for  your  treatment.  The  physician  to  whom  you  go  will, 
of  course,  also  have  to  notify  the  health  officer  that  he  has 
assumed  responsibility  for  your  treatment.  While  these 
measures  have  been  taken  to  protect  the  public  health,  I 
assure  you  that  they  are  even  more  for  your  own  benefit,  as 
this  is  a  most  treacherous  disease,  and  requires  most  efficient 
treatment  and  careful  supervision  if  you  are  to  be  protected 
from  very  serious  consequences  that  sometimes  ensue  later 
in  life,  such  as  aneurysm,  locomotor  ataxia  and  general 
paralysis  of  the  insane.  Moreover,  if  you  follow  this  treat- 
ment conscientiously  there  is  a  good  fighting  chance  that 
you  may  be  cured  and  that  you  can  later  marry  with  a  clear 
conscience,  something  that  you  could  hardly  have  been 
assured  of  had  not  these  provisions  been  made  for  your 
efficient  treatment  and  continuous  observation." 

What  becomes  of  the  poor  man?  The  physician  says: 
"Mr.  Smith,  I  am  very  sorry  to  tell  you  that  you  have  an 
undoubted  chancre  which  is  the  initial  lesion  of  syphilis. 
This  is  a  most  treacherous  general  disease  which  will  require 
much  expensive  treatment,  and  several  years  of  observation 
before  I  can  discharge  you  with  safety  to  yourself  or  the  public. 
If  you  feel  that  you  are  not  able  to  bear  the  expense  incident 
to  such  a  course  of  treatment,  I  am  glad  to  say  that  the  city 


246  PUBLIC  HEALTH  MEASURES 

has  established  a  dispensary  in  charge  of  men  who  are  very 
skilful  in  the  treatment  of  this  disease,  and  who  will  treat 
you  either  free  of  charge  or  with  only  a  small  charge  to  cover 
the  cost  of  the  remedies  used.  I  shall  be  obliged  by  the  law 
to  inform  the  health  officer  that  you  have  contracted  syphilis, 
and  I  am  sure  that  he  will  insist  that  you  receive  proper 
treatment  either  from  me  or  some  other  physician  or  from  the 
city  dispensary  to  which  I  just  recommended  you.  So  long 
as  you  take  your  treatment  you  need  not  fear  that  there  will 
be  any  publicity  in  the  matter." 

It  is  impossible  to  state  here  every  detail  of  such  a  conver- 
sation, and  it  is  even  probable  that  some  features  have  been 
omitted  which  should  be  explained  to  the  patient  at  greater 
length.  The  point  I  have  been  trying  to  make  is  that  such  a 
system  will  be  a  positive  benefit  to  the  man  himself,  to  the 
public  and  also  the  long-suffering  physician,  for  under  these 
circumstances  it  is  hardly  to  be  supposed  that  patients  will 
indulge  themselves  in  peripatetic  treatments.  They  will 
know  that  the  treatment  is  being  watched  by  the  physician, 
who  is  in  duty  bound  to  report  if  treatment  is  discontinued, 
and  there  will  be  little  inducement  to  change  physicians 
except  for  some  real  benefit  to  be  secured,  since  this  will 
simply  mean  a  fresh  report  to  the  health  office  and  a  fresh 
course  of  observation  and  treatment.  In  order  to  accomplish 
this  the  system  may  readily  be  devised  so  that  the  man  will 
be  under  observation  and  treatment  continuously  from  the 
time  the  diagnosis  is  made  until  he  is  cured,  or  until  the 
physician  is  willing  to  state  that  he  can  be  released  from 
further  treatment  without  danger  to  himself  or  to  the  public 
health.  Surely  such  a  safeguard  is  worth  as  much  to  the 
patient  as  to  the  community.  Such  watchful  care  will  be 
appreciated  by  the  more  intelligent  members  at  least,  and 
these  are  all  the  private  physician  will  have  to  deal  with. 
Other  classes  must  be  dealt  with  in  hospitals  and  dispensaries, 
which  is  admittedly  a  more  difficult  problem,  and  which  is 
considered  later. 

Finally,  it  may  be  mentioned  that  the  progressive  common- 
wealth of  Australia  has  recently  enacted  legislation  directed 
against  venereal  disease,  including  provisions  for  notifica- 


THE  CONTROL  OF   VENEREAL  DISEASES         247 

tion.  *  According  to  this  law,  on  developing  venereal  distease 
a  person  must  go  to  a  qualified  practitioner  for  treatment 
within  three  days.  If  he  fails  to  seek  treatment  he  may  be 
fined  or  imprisoned.  The  physician  must  report  to  the  health 
officials  the  age  and  sex  of  the  patient  and  a  diagnosis  of  his 
condition,  but  not  the  name  or  address.  The  patient  is  to 
return  for  treatment  at  least  once  a  month,  and  if  he  remains 
away  from  treatment  for  six  weeks,  the  physician,  under 
heavy  penalty,  must  notify  the  health  authorities,  giving 
this  time  the  patient's  name  and  address,  and  the  health 
authorities  must  bring  the  patient  into  court  and  compel 
him  to  have  treatment.  The  patient  may  change  his  physi- 
cian, but  on  doing  this  he  must  disclose  the  name  of  his 
previous  physician,  who  must  be  notified  by  the  second 
physician  that  the  patient  is  now  under  treatment  by  the 
latter.  Treatment  must  be  continued  until  the  patient  can 
obtain  a  satisfactory  certificate  of  cure.  The  health  boards 
have  authority  to  apprehend  any  person  suspected  of  having 
a  venereal  disease  that  is  not  being  treated  and  to  compel 
him  to  submit  to  examination  by  qualified  physicians  and  to 
obtain  a  certificate  of  health,  or  to  submit  to  treatment  until 
such  a  certificate  can  be  obtained.  As  this  legislation  has 
only  been  passed  after  a  thorough  study  of  the  subject,  and 
after  an  interval  during  which  reporting  by  number  was 
practised,  it  must  be  assumed  that  in  Australia,  at  least, 
they  are  convinced  that  notification  is  both  practicable  and 
desirable. 

If  notification  is  to  be  adopted  in  this  country  it  can  only 
be  enforced  in  case  public  opinion  is  behind  the  law.  Nor 
can  efficient  treatment  for  venereal  diseases  be  provided  by 
the  community  until  public  opinion  will  support  the  necessary 
institutions.  For  all  of  these  reasons  it  is  essential  that  the 
public  be  informed  in  a  proper  way  in  regard  to  the  exact 
facts. 

Publicity. — ^Venereal  diseases  have  spread  to  their  present 
alarming  extent  because  the  public  has  not  been  informed  of 
the  facts.    From  the  very  nature  of  the  case  an  individual 

*  See  Appendix  for  this  law. 


248  PUBLIC  HEALTH  MEASURES 

suffering  from  venereal  disease  desires  to  prevent  his  infection 
from  becoming  known.  His  physician,  of  course,  preserves 
the  secret.  Pubhc  discussion  of  the  subject  has  been  tabooed. 
Consequently,  although  many  of  the  people  with  whom  the 
average  person  is  brought  in  contact  either  suffer  or  have 
suffered  from  these  infections,  he  remains  unaware  of  this 
and  naturally  assumes  that  these  diseases  are  much  less 
common  than  is  actually  the  fact.  Physicians  realize  the 
prevalence  of  venereal  diseases  and  for  a  number  of  years  the 
medical  journals  have  been  filled  with  statistics  of  the  most 
alarming  nature,  but  these  articles  are  seldom  seen  by  the 
layman,  or  if  he  happens  to  see  one,  he  concludes  that  this  is 
the  effusion  of  one  more  crank.  The  general  public  is  there- 
fore in  total  ignorance  of  the  alarming  frequency  of  venereal 
diseases.  Even  at  the  present  day,  when  these  subjects  are 
discussed  more  openly  than  ever  before  and  theaters  are 
filled  with  people  who  witness  a  play  like  "  Damaged  Goods, " 
few  realize  how  common  the  damaged  goods  really  are.  If 
people  think  of  the  subject  at  all  they  simply  think  of  it  as 
something  that  exists,  but  never  consider  the  possibility  of 
such  a  disease  invading  their  own  family.  The  majority  of 
people  in  our  Southern  cities  who  employ  negro  servants  have 
the  infection  in  their  households  at  the  present  time,  though 
it  must  be  added  that  the  danger  of  contracting  infection 
through  the  ordinary  contact  with  a  domestic  must  be  very 
slight,  since  so  few  cases  are  reported  originating  from  this 
source.  The  remedy  for  the  venereal  disease  problem  lies 
in  publicity  of  the  proper  kind.  Certainly  prurient  or 
curiosity-stimulating  articles  in  the  papers  are  not  desirable, 
but  it  is  believed  desirable  that  the  health  ofScer  should 
publish  the  facts  as  to  the  infection  in  his  particular  com- 
munity. *  It  is  a  principle  lying  at  the  foundation  of  democ- 
racy that  when  the  people  have  the  facts  they  can  be  trusted 
to  take  the  proper  action.  The  facts  should  therefore  be 
given  by  circulars  from  the  board  of  health,  which  should  be 
distributed  to  the  heads  of  households.  It  is,  of  course,  a 
matter  of  general  knowledge  that  several  up-to-date  health 

*  See  Appendix  for  some  of  the  methods  of  publicity  used  by  the  city 
of  Rochester,  N.  Y. 


THE  CONTROL  OF   VENEREAL  DLSEASES  249 

departments  have  already  raised  the  taboo  on  venereal 
diseases  and  discuss  the  subject  in  their  official  bulletins.  But 
the  average  bulletin  issued  by  the  health  department  does  not 
have  a  sufficiently  wide  circulation  for  this  purpose.  Informa- 
tion in  regard  to  venereal  diseases  should  be  printed  in  smaller 
circulars  and  addressed  to  the  heads  of  households.  When  the 
information  obtainable  has  become  generally  available  the 
health  officer  will  no  longer  find  his  hands  tied  in  all  attempts 
to  secure  action  leading  toward  the  reduction  of  venereal 
diseases,  but  will  have  behind  him  an  active  public  opinion 
which  will  peremptorily  demand  that  something  be  done  to 
correct  the  present  state  of  affairs. 

With  public  opinion  thus  aroused  the  health  officer  may 
next  indicate  the  absolute  necessity  for  notification  if  any 
real  progress  is  to  be  made  in  the  treatment  of  venereal  dis- 
eases from  the  public  health  point  of  view.  He  may  point  out 
the  fact  that  at  present  it  can  be  safely  said  there  is  no  com- 
munity in  the  United  States  where  the  exact  facts  in  regard 
to  the  prevalence  of  syphilis  and  gonorrhea  are  known,  that 
they  never  will  become  known  without  a  system  of  notifica- 
tion, and  that  many  of  these  cases  receive  insufficient  treat- 
ment so  that  they  are  a  constant  source  of  danger  to  the 
community.  Objections  may  be  raised  to  such  a  course  of 
education  of  the  public  by  the  health  department,  and  it  may 
be  granted  that  in  such  a  process  some  mistakes  will  be  made. 
But  no  mistake  could  be  so  bad  as  the  present  lethargy  and 
laissez-faire.    We  can  at  least  learn  by  mistakes. 

The  Provision  of  Proper  Facilities  for  Treatment. — We  have 
decided  that  our  future  progress  in  the  control  of  syphilis 
and  other  venereal  diseases  must  come  through  systematic 
treatment  and  that  notification  cannot  be  effective  until 
ample  facilities  are  provided  for  treatment.  It  becomes 
pertinent  tjierefore  to  inquire  into  the  sufficiency  and 
efficiency  of  our  present  institutions  for  this  purpose  in  order 
that  we  may  see  what  improvements  must  be  made  in  the 
near  future.  Unfortunately  but  little  that  is  good  can  be 
said  of  our  present  provision  for  the  treatment  of  these 
diseases,  for  it  is  neither  sufficient  nor  efficient. 

The  majority  of  general  hospitals  have  refused  admission 


250  PUBLIC  HEALTH  MEASURES 

to  patients  suffering  from  venereal  diseases,  no  doubt  because 
the  managers  of  these  institutions  have  beheved  that  they 
were  thereby  protecting  the  patients  that  were  admitted 
and  that  many  patients  might  be  deterred  from  seeking  the 
benefits  of  the  hospital  if  they  knew  that  venereal  diseases 
were  admitted.  That  this  statement  is  no  gross  exaggeration 
is  shown  by  the  following  figures  presented  by  Stokes/  who 
says  that  in  1914  it  was  estimated  that  the  city  of  London, 
with  7,000,000  inhabitants,  had  only  163  beds  available  for 
the  treatment  of  venereal  disease,  and  the  same  condition 
obtained  throughout  Great  Britain.  Of  30  general  hospitals 
in  New  York  City  a  recent  investigation  showed  that  only 
10  received  recognized  cases  of  syphilis;  13  of  30  will  not 
even  receive  medical  cases  with  complications  of  syphilis  or 
gonorrhea.  "Chicago  has  the  Cook  County  Hospital,  the 
only  special  service  I  know  of  in  the  city,  200  beds  to  2,000,000 
people. "  The  present  insufficiency  of  hospital  facilities  may 
be  shown  also  by  the  words  spoken  in  praise  of  present 
facilities.  Thus  Post^  says:  The  Massachusetts  General 
Hospital  has  maintained  for  nearly  two  years  a  separate 
department  for  syphilitics,  with  large  out-patient  facilities 
and  a  few  beds.  The  Boston  City  Hospital  has  practically 
done  the  same  thing.  The  children's  hospital  has  changed  its 
policy  and  now  treats  children  with  syphilis.  The  Boston 
dispensary  has  for  many  years  paid  considerable  attention 
to  these  cases.  Worcester  has  provided  a  hospital  ward  for 
their  care.  The  city  of  Memphis  within  a  year  has  arranged 
matters  so  that  a  doctor  can  send  a  man  with  syphilis  to  a 
hospital,  and  he  is  received  and  treated  as  a  matter  of  course 
as  if  it  were  any  other  disease. 

What  a  state  of  affairs  is  disclosed  by  such  comments! 
Pontoppidan  on  the  basis  of  his  large  experience  with  the 
Danish  system  estimates  that  one  bed  to  2000  of  the  popula- 
tion is  insufficient  to  care  for  the  sexual  diseases.  Even  on 
this  very  conservative  estimate,  Chicago  should  have  1000 
beds  and  New  York  should  have  2500  beds.  But  all  con- 
temporary comment  clearly  indicates  that  the  attitude  of 
the  general  hospital  toward  syphilis  and  other  venereal 
diseases  is  slowly  changing.     We  now  know  that  a  large 


THE  CONTROL  OF   VENEREAL  DLSEASES  251 

percentage  of  the  patients  admitted  to  all  hospitals  suffer 
from  a  syphilitic  infection  in  addition  to  the  disease  or  as 
the  real  cause  of  the  disease  for  which  they  were  admitted. 
If  from  15  to  25  per  cent,  of  all  the  patients  admitted  are 
syphilitic,  it  seems  a  little  foolish  to  continue  to  refuse  to 
admit  syphilitics  to  our  general  hospitals.  And  this  change 
of  opinion  should  be  accelerated,  for  it  is  these  general 
hospitals  that  must  provide  the  beds  for  the  treatment  of 
syphilitics,  if  systematic  treatment  is  to  be  adopted  by  the 
community.  Special  hospitals  for  the  treatment  of  venereal 
diseases  will  not  serve  the  purpose,  for  while  any  patient 
might  go  to  a  general  hospital  for  the  treatment  of  these 
conditions,  very  few  would  seek  assistance  in  a  hospital 
openly  devoted  to  the  treatment  of  venereal  diseases  because 
of  the  stigma  necessarily  attached.  This  fact  was  recog- 
nized by  the  Royal  Commission,  which  reported  against 
special  hospitals  and  clinics  for  these  conditions.  Every 
general  hospital  should  have  a  ward  or  wards  assigned  for 
the  treatment  of  syphilis,  the  exact  number  of  beds  depending 
upon  the  magnitude  of  its  clientele.  It  is  recognized  that 
the  majority  of  the  treatment  of  syphilitics  can  be  carried 
out  as  well  by  the  out-patient  department,  but  hospital 
beds  must  be  available  for  patients  in  the  primary  and  active 
secondary  stages  of  the  disease  in  order  to  provide  isolation 
and  protect  the  public  during  the  time  that  such  cases  are  a 
menace  to  those  with  whom  they  come  in  contact.  Further- 
more, beds  are  necessary  in  order  that  salvarsan  or  similar 
drugs  may  be  administered  under  proper  safeguards.  The 
patients  should  remain  in  hospital  for  at  least  twenty-four 
hours  after  receiving  this  remedy.  As  no  patient  would 
occupy  a  bed  long,  since  salvarsan  usually  causes  a  prompt 
disappearance  of  the  external  lesions,  the  situation  is  com- 
paratively simple  today  as  compared  with  former  years 
when  long  courses  of  mercurials  were  necessary  before  the 
lesions  .were  under  control.  While  it  would  be  foolish  to 
attempt  to  prescribe  the  number  of  beds  or  the  size  of  wards 
that  general  hospitals  should  maintain  for  the  treatment 
of  syphilitics,  it  will  be  generally  admitted  that  present 
facilities  are  sadly  deficient,  and  that  the  extension  of  those 


252  PUBLIC  HEALTH  MEASURES 

facilities  should  be  among  the  first  steps  to  be  taken  to  con- 
trol this  disease. 

It  will  probably  also  be  admitted  without  any  long  array 
of  statistics  that  treatment  in  most  of  our  out-patient 
departments  and  clinics  for  venereal  diseases  is  inefficient. 
As  examples,  it  may  be  said  that  White^**  found  that  of  1016 
cases  treated  for  syphilis  in  a  Massachusetts  hospital,  20 
per  cent,  consulted  them  but  once,  only  52  per  cent,  continued 
treatment  six  months  or  more,  and  but  45  per  cent,  per- 
severed for  one  year  or  more,  and  38  per  cent,  for  two  years 
or  more.  These  figures,  bad  as  they  are,  speak  well  for  that 
particular  hospital  under  existing  circumstances,  and  it  is 
believed  that  few  clinics  hold  even  38  per  cent,  of  their  cases 
of  syphilis  for  two  years  or  more. 

A  recent  survey*  to  determine  how  many  clinics  in  New 
York  were  meeting  the  requirements  of  the  Associated  Out- 
patient Clinics,  reported  only  7  approved  clinics  for  syphi- 
litics  out  of  27.  Many  of  these  could  with  small  effort  meet 
the  requirements,  but  12  were  found  to  be  hopelessly  bad. 

With  regard  to  gonorrhea,  Platt^^  found  that  in  four 
genito-urinary  clinics  in  New  York,  of  the  gonorrheal 
patients  in  the  course  of  a  year,  8  per  cent,  were  discharged 
cured,  17  per  cent,  ceased  treatment  of  their  own  accord, 
improved  but  not  cured,  and  75  per  cent,  ceased  treatment 
unimproved:  28  per  cent,  made  one  visit,  11  per  cent,  made 
two  visits,  7  per  cent,  made  three  visits,  and  6  per  cent, 
made  four  visits;  so  that  52  per  cent,  made  less  than  five 
visits.  The  fault  for  these  conditions  is  undoubtedly  on  the 
part  of  the  patients  who  are  too  ignorant  to  continue  treat- 
ment, but  it  is  probably  due  to  some  extent  to  the  conditions 
obtaining  in  the  dispensaries.  These  dispensaries  are  for  the 
most  part  poorly  equipped,  in  the  poorest  rooms  the  hospital 
affords,  as  there  is  a  tendency  to  believe  that  any  accommo- 
dations are  good  enough  for  the  venereal  clinic.  There  is 
little  privacy,  and  if  the  hospital  is  connected  with  a  medical 
school  the  patient  is  seized  upon  to  furnish  clinical  material 
to  the  students.  As  a  result  of  this  lack  of  privacy,  only  the 
most  callous  will  go  to  such  clinics.     In  many  the  medical 

*  Barringer  and  Piatt,  Social  Hygiene,  vol.  i.  No.  3. 


THE  CONTROL  OF   VENEREAL  DISEASES  253 

attendants  are  insufficient  in  number  to  give  the  cases  the 
attention  that  they  should  obtain,  and  they  are  usually 
young  men  who  are  seeking  experience,  rather  than  well- 
trained  men,  who  for  the  most  part  are  too  busy  with  their 
private  practice  to  do  much  dispensary  work;  and  in  many 
the  vicious  system  of  prescribing  by  number  obtains,  so  that 
the  patient  feels  that  he  is  receiving  only  routine  attention. 
As  a  matter  of  fact  the  patient  may  be  mistaken,  for  a  per- 
manganate injection  or  mercurial  ointment  for  inunctions 
will  not  vary  for  different  patients,  and  might  well  for  con- 
venience be  prescribed  by  number.  But  the  patient  knows 
that  private  physicians  do  not  prescribe  in  this  routine  way, 
and  it  is  a  poor  method  to  use  if  the  confidence  of  the  patient 
is  to  be  secured. 

While  not  all  of  these  criticisms  apply  to  individual  dis- 
pensaries, and  a  few  are  above  criticism,  it  will  probably  be 
generally  admitted  that  the  enlargement  and  improvement 
of  dispensary  facilities  is  equally  important  with  the  improve- 
ment of  hospital  facilities.  As  both  hospital  and  dispensary 
facilities  are  what  they  are  solely  because  of  lack  of  funds 
for  their  support,  it  will  become  necessary  for  the  city  to 
bear  at  least  part  of  the  expense  of  such  improvements,  and 
this  is  a  logical  requirement  since  the  improvements  are  to 
be  made  for  the  purpose  of  securing  systematic  treatment  for 
the  direct  benefit  of  the  public  health.  It  is  a  measure  that 
will  produce  far  more  results  than  the  elaborate  precautions 
that  are  now  taken  by  many  cities  for  terminal  disinfection 
after  infectious  diseases,  and  sanitary  officers  should  be  pre- 
pared to  advocate  that  a  respectable  amount  of  the  public 
funds  assigned  to  the  Health  Department  should  be  set  aside 
for  the  support  of  hospitals  and  clinics  for  the  treatment  of 
these  diseases.  New  York  City  has  established  a  free  clinic 
for  diagnosis  and  advice. 

Admitting  that  the  hospital  has  provided  efficient  treat- 
ment for  the  patient,  it  has  still  not  performed  its  whole  duty. 
Syphilis  is  notoriously  a  family  disease,  and  the  other  cases 
in  the  family  should  receive  attention.  This  class  of  work 
means  a  social  service  connected  with  the  hospital,  and  a 
number  of  hospitals  have  instituted  such  departments. 


254  PUBLIC  HEALTH  MEASURES 

From  the  public  health  point  of  view  another  service 
remains  to  be  performed.  In  the  case  of  the  syphilitic 
patients  with  a  primary  lesion,  an  endeavor  should  be  made 
to  determine  the  source  of  the  infection.  According  to 
Blaisdell/"  one  clinic  had  236  single  men  and  35  single 
women  with  syphilis.  With  few  exceptions  the  236  single 
men  represented  as  many  different  women  who  are  active 
foci  of  infection  but  who  receive  no  treatment.  As  most 
of  these  women  are  prostitutes  who  may  be  daily  infecting 
other  men,  the  desirability  of  bringing  them  under  treat- 
ment is  obvious.  This  matter  will  be  referred  to  later  at 
greater  length. 

We  conclude,  therefore,  that  the  following  are  the  logical 
and  necessary  steps  to  be  taken  by  any  community  in  the 
endeavor  to  control  syphilis : 

I.  By  the  Health  Officer. 

1.  A  proper  system  of  publicity  by  means  of  which  the 
facts  with  regard  to  syphilis  and  other  venereal  diseases  may 
be  brought  to  the  attention  of  tax  payers  and  heads  of 
families,  with  a  view  of  enlisting  support  for  the  passage 
of  a  law  requiring  notification  and  for  increased  facilities  for 
treatment  and  the  provision  of  the  necessary  funds. 

2.  An  endeavor  to  secure  the  passage  of  a  good  notifica- 
tion law;  and  after  its  passage,  the  creation  of  the  machinery 
for  its  enforcement. 

3.  The  provision  of  adequate  laboratory  facilities  for  the 
diagnosis  of  these  diseases. 

4.  The  establishment  of  a  sufficient  number  of  dispensaries 
and  clinics,  day  and  evening,  pay  and  free,  to  accommodate 
all  patients  who  may  suffer  from  syphilis  and  are  unable  to 
pay  a  private  physician,  and  for  whom  existing  facilities 
provided  by  hospitals  are  insufficient. 

5.  The  periodic  inspection  of  hospitals  and  dispensaries, 
to  ensure  that  they  conform  with  already  formulated  stand- 
ards of  equipment  and  management:  such  institutions 
should  be  criticised  by  recognized  efficiency  tests. 

6.  The  dissemination  of  information  to  the  profession 
with  regard  to  the  facilities  for  diagnosis  and  treatment 
afforded  by  the  health  department,  and  with  regard  to  the 
standard  of  cure  that  will  be  acceptable  to  the  department. 


THE  CONTROL  OF   VENEREAL  DISEASES  255 

II.  By  hospitals.     See  Stokes.'' 

1.  The  organization  of  a  department  of  syphilis  within 
the  hospital. 

(1)  The  provision  of  a  sufficient  number  of  beds  to  meet 
all  needs. 

(2)  The  provision  of  adequate  modern  laboratory  facilities 
for  the  purpose  of  diagnosis  and  to  control  the  treatment. 

(3)  Personnel. — The  department  to  be  under  a  chief  of 
service  who  would  be  a  highly  trained  man  who  would  serve 
continuously,  and  who  should  be  directly  responsible  for 
everything  pertaining  to  the  service.  He  should  be  assigned 
a  corps  of  assistants,  including  physicians  who  are  willing 
to  serve,  interns  and  nurses. 

(4)  The  establishment  of  a  social  service  corps  of  nurses 
who  would  follow  up  each  case  treated  by  the  hospital.  They 
should  be  especially  instructed  so  as  to  reach  other  cases  of 
familial  syphilis,  so  that  they  can  carry  assistance  to  syphi- 
litic homes  rather  than  knowledge  that  is  discouraging  and 
detrimental. 

(5)  A  routine  Wassermann  on  all  patients  to  detect  un- 
recognized syphilitics.  Such  cases,  when  detected,  should  be 
treated  for  that  disease  by  the  department  of  syphilis.  In 
this  way  the  responsibility  for  the  treatment  of  this  disease 
will  all  be  borne  by  the  one  department  having  the  necessary 
equipment,  experience  and  trained  social  workers. 

2.  The  out-patient  department. 

(1)  Each  hospital  should  have  a  special  out-patient  depart- 
ment for  the  treatment  of  syphilis  with  the  proper  accom- 
modations. 

(2)  Organization. — It  should  form  a  part  of  the  department 
of  syphilis,  and  like  the  hospital  service  should  be  under 
the  direction  of  the  chief  of  service  who  would  therefore  be 
responsible  also  for  the  proper  management  of  this  out- 
patient service.  A  separate  staff  of  assistants  would  be 
necessary.  Patients  discharged  from  the  hospital  would 
report  here  at  regular  intervals  until  discharged  as  cured. 
A  card  index  system  would  show  for  each  day  the  patients 
that  were  to  report  for  observation.  Clerical  assistance  in 
the  keeping  of  these  records  will  be  indispensable,  as  is  also 
a  medical  service  skilled  in  diagnosis  and  treatment. 


256  PUBLIC  HEALTH  MEASURES 

(3)  Equipment. — The  dispensary  must  have  at  hand 
technical  equipment  for  diagnosis  and  treatment,  particu- 
larly a  dark-field  microscope  for  the  diagnosis  of  the  primary 
lesions.  A  serological  laboratory  is  not  essential,  as  speci- 
mens can  be  sent  to  the  laboratory  of  the  hospital  which  is 
part  of  the  department. 

(4)  To  be  of  real  service  to  the  community  this  dispensary 
must  be  accessible.  It  should  be  located  on  a  car  line,  and 
the  facilities  provided  must  be  available  at  such  a  place  and 
at  such  hours  as  do  not  involve  undue  sacrifice  of  time,  money, 
or  convenience  to  the  persons  who  need  treatment.  This 
practically  means  evening  hours,  as  poor  people  cannot 
afford  to  stop  work  or  forfeit  their  pay  in  order  to  visit  a 
dispensary  so  long  as. they  are  not  absolutely  incapacitated. 

(5)  The  cost,  if  any,  of  these  facilities  must  be  within  the 
means  of  the  patients. 

(6)  These  facilities  should  be  organized  with  due  regard 
to  the  proper  correlation  with  the  Health  Department  of 
the  City  or  State. 

Treatment  of  Prostitutes. — It  will  be  seen  that  no  special 
provision  has  been  made  for  the  treatment  of  prostitutes, 
and  this  is  as  it  should  be  because  any  approach  to  reglemen- 
tation  is  to  be  avoided,  and  because  it  may  be  assumed  that 
an  attempt  at  suppression  is  being  made.  Nevertheless,  as 
the  traffic  cannot  be  entirely  suppressed,  it  must  be  possible 
for  such  of  these  women  as  are  infected  to  secure  treatment, 
and  it  is  particularly  desirable  that  the  treatment  should  be 
supervised  and  continued  until  they  are  no  longer  a  menace 
to  the  public  health.  If  the  system  of  treatment  already 
described  were  in  operation,  these  results  would  undoubtedly 
be  very  largely  secured.  It  is  not  to  be  supposed  that  pros- 
titutes enjoy  being  syphilitic,  or  that  they  would  not  apply 
for  treatment  were  it  available  and  within  their  means, 
without  exposure  to  undue  publicity.  Those  who  can  afford 
it  will  go  to  private  physicians  as  they  do  today;  they  will 
be  reported  to  the  health  officer  like  any  other  patient  suffer- 
ing from  syphilis,  and  like  any  other  patient  will  be  kept 
under  observation  until  they  have  complied  with  the  recog- 
nized standards  and  can  be  discharged.    If  she  is  unable  to 


THE  CONTROL  OF   VENEREAL  DISEASES         257 

bear  this  expense,  it  should  be  perfectly  possible  to  secure 
treatment  at  the  hospitals  or  dispensaries  just  as  do  other 
patients.  It  is  not  to  be  expected  that  respectable  women 
will  make  free  use  of  hospital  facilities  if  they  think  they  are 
to  be  associated  with  women  of  the  underworld.  But  the 
tendency  today  in  hospital  construction  is  not  to  build  large 
wards  but  rather  smaller  wards  or  rooms  for  the  accommo- 
dation of  a  small  number  of  patients.  This  enables  certain 
diseases  to  be  segregated  with  greater  ease,  and  ensures  a 
greater  amount  of  privacy.  Hospitals  should  keep  such  a 
small  ward  or  room  for  women  known  to  be  prostitutes,  and 
such  women  in  the  infectious  stages  of  syphilis  could  be  thus 
treated  without  exposing  them  to  needless  publicity  and 
without  wounding  the  susceptibilities  of  other  patients.  A 
well-equipped  department  of  syphilis  should  have  a  number 
of  private  rooms  for  both  women  and  men  in  the  infectious 
stages,  thereby  securing  both  isolation  and  privacy,  and  for 
obvious  reasons  these  rooms  should  be  available  without 
the  usual  exorbitant  charges  for  private  rooms. 

However,  in  addition  to  this  general  provision  for  treatment 
for  all  infections,  an  effort  should  be  made  in  every  case  of 
primary  or  early  secondary  syphilis  to  determine  the  source 
of  the  infection.  This  will  frequently  be  impossible,  but  in 
many  cases  a  man  is  both  able  and  willing  to  say  where  the 
infection  was  acquired.  In  every  such  case  where  the  source 
of  the  infection  can  be  traced,  a  health  officer  should  visit  the 
case  and  the  diagnosis  should  be  confirmed,  either  by  a  clinical 
examination  or  by  a  Wassermann  reaction  and  by  both  when 
possible.  Treatment  should  then  be  urged  and  if  neces- 
sary, insisted  upon.  Should  the  patient  be  unable  to  pay  a 
physician  the  treatment  should  be  furnished  by  physicians 
employed  by  the  city.  The  law  should  provide  that  if  the 
diagnosis  is  certain  and  the  patient  is  unwilling  to  accept  such 
treatment,  arrest  and  confinement  may  follow  at  the  dis- 
cretion of  the  health  officer.  Thus  a  prostitute  known  to  be 
infected  would  be  compelled  to  receive  treatment,  and  this 
provision  would  also  include  other  cases  that  will  not  accept 
treatment  voluntarily.  This  constitutes  no  abuse  of  personal 
liberty.  A  person  who  refuses  to  submit  to  the  recognized 
17 


258  PUBLIC  HEALTH  MEASURES 

treatment  for  a  dangerous  communicable  disease  is  sub- 
jecting the  entire  community  to  danger  of  infection,  and  the 
power  of  society  to  protect  itself  would  be  questioned  in  the 
case  of  no  other  disease.  No  one  considers  that  the  personal 
liberty  of  an  individual  suffering  from  cholera  is  infringed 
when  he  is  quarantined,  and  there  is  no  reason  why  a  person 
suffering  from  syphilis  in  an  infectious  stage  could  not  be 
restrained  in  a  similar  manner  except  that  it  has  not  been 
customary  to  do  so.  Nor  is  it  to  be  supposed  that  arrests 
or  quarantines  would  be  necessary  in  any  but  the  most 
exceptional  cases.  The  power  to  make  an  arrest  in  a  case  of 
this  kind  would  simply  give  power  to  enforce  treatment,  for 
there  are  very  few  who  would  refuse  to  accept  treatment 
if  they  knew  that  quarantine  or  arrest  would  follow  this 
refusal. 

In  a  similar  way,  in  the  case  of  women  arrested  for  dis- 
orderly conduct  or  other  breaches  of  public  morals,  a  Wasser- 
mann  reaction  should  be  made  by  the  city  laboratory  as  a 
matter  of  routine.  If  positive,  or  should  a  clinical  examina- 
tion be  made,  preferably  by  a  woman,  and  should  syphilis 
be  found,  the  case  should  be  treated.  The  same  rule  should 
also  be  applied  to  men  arrested  for  similar  offences. 

It  is  somewhat  beyond  the  limits  of  this  work  to  discuss 
the  sociological  aspects  of  prostitution.  It  is  sufficiently 
apparent,  however,  that  no  attempt  to  repress  prostitution 
can  be  successful  which  does  not  endeavor  to  provide  some 
other  occupation  for  the  prostitute.  Every  city  that  attempts 
such  a  campaign  should  establish  a  corrective  institute  for 
such  w^omen,  where  they  may  be  reformed  if  possible,  and  at 
least  educated  to  perform  some  useful  labor  by  which  they 
may  earn  a  living  wage  when  returned  to  the  world. 

If  an  effort  is  to  be  made  to  suppress  prostitution,  solicita- 
tion on  the  streets  must  be  suppressed.  Yet  what  is  accom- 
plished by  arresting  and  fining  the  street-walker?  When  she 
is  released  she  must  simply  work  a  little  harder  to  recoup 
herself.  Any  woman  arrested  for  this  offence  who  cannot 
give  an  account  of  herself,  i.  e.,  who  has  no  other  means  of 
support,  should  be  sent  to  such  a  corrective  institution  and 
should  remain  there  until  there  is  at  least  some  hope  that  she 


THE  CONTROL  OF   VENEREAL  DISEASES  259 

will  enter  some  other  occupation.  Here  then  is  the  best 
opportunity  to  provide  treatment  for  the  infected.  A 
thorough  medical  examination  becomes  essential  if  such  an 
institution  is  to  be  conducted  in  accordance  with  humane 
considerations,  and  as  such  women  will  be  confined  for  a 
considerable  period  of  time,  there  is  ample  opportunity  for 
treatment  which  will  produce  either  a  cure  or  will  at  least 
practically  eliminate  all  danger  of  transmitting  syphilis,  even 
should  the  attempt  at  reformation  fail. 

Salvarsan. — It  will  be  seen  that  many  of  the  measures  sug- 
gested depend  for  their  efficacy  upon  the  provision  of  treat- 
ment either  free  or  at  a  nominal  cost  to  poor  patients.  No 
other  method  of  compulsory  treatment  can  succeed,  for  it  is 
impossible  to  insist  upon  a  treatment  that  is  beyond  the 
means  of  the  patient  to  procure.  It  has  been  sufficiently 
demonstrated  that  salvarsan  is  a  specific  in  the  treatment  of 
syphilis,  and  while  the  fallacy  of  our  original  hopes  of  a 
''therapia  sterilizans  magna"  is  now  apparent,  this  drug  still 
remains  the  most  potent  remedy  which  we  can  command. 
Although  it  is  still  possible,  as  in  former  times,  to  treat 
syphilis  by  mercury  alone  or  in  combination  with  the  iodides 
in  the  later  stages  of  the  disease,  such  treatment  is  distinctly 
inferior  in  its  results  to  the  proper  combination  of  salvarsan 
and  mercury.  From  the  stand-point  of  public  health  alone, 
salvarsan  has  the  merit  of  causing  a  much  more  rapid  dis- 
appearance of  the  infectious  lesions  than  can  be  produced  by 
the  administration  of  mercury  alone.  Since  there  can  be  no 
dissent  from  these  statements  which  are  almost  axiomatic, 
it  follows  that  cities  and  States  that  wish  to  enforce  efficient 
treatment  for  all  syphilitics  must  be  prepared  to  furnish 
salvarsan  in  large  quantities.  At  present  prices  the  cost  of 
such  a  procedure  would  be  prohibitive.  Some  conception  of 
the  magnitude  of  this  expense  may  be  derived  from  the 
experience  of  the  United  States  army,  which  in  1914,  for  an 
army  of  less  than  100,000  men,  purchased  3610  doses  of  sal- 
varsan and  5770  doses  of  neosalvarsan.  If  the  city  of  New 
York,  with  a  population  of  5,000,000,  bought  salvarsan  on  a 
similar  scale  at  similar  prices,  it  would  cost  the  city  $1,641,500 
annually.    The  price  of  salvarsan  has  been  little  less  than  a 


260         PUBLIC  HEALTH  MEASURES 

crime.  As  the  British  Medical  Journal  has  said  (April  1, 
1916,  p.  493):  "Salvarsan  has  always  been  a  drug  of  the 
proprietary  class,  made  in  an  atmosphere  of  mystery,  under 
a  patent  giving  a  misleading  account  of  its  preparation, 
produced  at  small  cost  and  sold  at  a  very  high  price."  The 
luster  attaching  to  Ehrlich's  name  as  the  result  of  his  scientific 
discoveries  has  been  badly  dimmed  by  the  gross  commercial- 
ism with  which  he  has  permitted  his  product  to  be  exploited. 
Dr.  Shamberg,  Director  of  the  Department  of  Derma- 
tological  Research  of  the  Philadelphia  Polyclinic,  which  has 
been  manufacturing  this  product,  states  that  he  can  make  it 
for  one  dollar  a  dose,  and  that  there  is  every  reason  to  believe 
that  when  the  procedure  is  standardized  and  with  manu- 
facture on  a  large  scale,  salvarsan  can  be  manufactured  for 
fifty  cents  a  dose.  For  a  product  no  better  we  were  compelled 
to  pay  $3.50  before  the  war.  There  is  every  evidence  that 
Congress  in  the  Trading  with  the  Enemy  act  will  repeal  this 
patent,  at  least  during  the  war.  But  everyone  interested  in 
public  health  work  should  endeavor  to  impress  our  legis- 
lators with  the  necessity  of  making  this  action  permanent. 
Whatever  the  ethics  of  the  matter  from  a  professional  point 
of  view,  Ehrlich  is  now  dead  and  cannot  profit  further  from 
the  patent.  There  is  therefore  no  valid  reason  why  the 
patent  should  be  reestablished  after  the  war  to  the  prejudice 
of  the  public  health.  With  salvarsan  marketed  at  a  price 
of  fifty  cents  a  dose,  the  price  for  which  it  can  be  made  in  this 
country  without  the  protection  of  a  patent,  the  salvarsan 
that  at  $3.50  per  ampoule  would  cost  the  city  of  New  York 
$1,641,500  would  then  cost  only  $234,500.  It  must  not  be 
supposed,  however,  that  this  sum  would  actually  have  to 
be  spent  for  salvarsan  by  the  city.  The  calculation  is  based 
on  army  figures,  and  proportionally  much  less  would  be 
required  for  the  women  and  children  in  a  mixed  population. 
Moreover,  it  need  only  be  furnished  by  the  city  for  the  poor 
who  cannot  purchase  it  for  themselves,  and  were  the  price  re- 
duced to  fifty  cents,  there  would  be  only  relatively  few  cases  for 
which  the  city  would  be  compelled  to  purchase  the  drug.  At 
the  old  price  of  $3.50,  with  a  considerable  fee  to  the  physician 
administering  it,  the  drug  was  out  of  reach  of  a  large  part  of 


THE  CONTROL  OF   VENEREAL  DISEASES         261 

the  population.  Enough  has  been  said  to  indicate  the  advisa- 
biHty  of  permanently  abrogating  the  patent  on  salvarsan. 

Public  Health.  Measures  for  the  Prevention  of  Syphilis  In- 
sontium. — Innocent  syphilis  is  generally  the  result  by  one  or 
two  removes  of  syphilis  acquired  by  promiscuity.  Therefore 
it  may  be  expected  that  if  the  measures  taken  against  the 
latter  are  effective,  innocent  syphilis  will  become  much  more 
infrequent  than  is  the  case  at  present.  But  certain  measures 
may  still  be  taken  by  the  public  health  authorities  to  guard 
against  such  accidental  transmission.  One  of  the  most 
important  of  these  is  some  control  of  barber  shops. 

Barber  Shops. — A  considerable  number  of  accidental 
infections  have  been  traced  to  barber  shops,  and  have 
generally  occurred  after  a  cut  which  has  been  dressed  by  a 
piece  of  court-plaster  wet  with  the  saliva  of  a  syphilitic 
barber  or  touched  by  an  alum  stick  similarly  wet  with  infec- 
tive saliva.  An  ordinance  something  like  the  following  is 
in  use  in  a  number  of  cities: 

Section  I.     Every    barber    shop    within    the    town    of 

.     . shall  be  open  to  inspection  by  the 

Board  of  Health  at  any  time,  and  the  following  rules  shall  be 
observed  therein: 

1.  All  barber-  shops,  together  with  all  furniture,  shall  be 
kept  in  a  clean  and  sanitary  condition. 

2.  Mugs,  shaving  brushes,  razors,  scissors,  clipping 
machines  shall  be  sterilized  by  immersion  in  boiling  water 
after  each  separate  use.  Combs  and  brushes  shall  be  thor- 
oughly cleaned  with  soap  and  water  after  each  separate  use. 

3.  Clean  towels  shall  be  used  for  each  person. 

4.  Alum  or  other  material  to  stop  the  flow  of  blood  shall  be 
applied  only  on  a  clean  towel  or  other  clean  cloth.  The 
wetting  of  alum  sticks  or  court-plaster  with  saliva  is  strictly 
prohibited. 

5.  The  use  of  powder-puffs  and  sponges  is  prohibited, 
except  that  such  articles  owned  by  a  customer  may  be  used 
on  him. 

6.  Every  barber  shall  thoroughly  cleanse  his  hands  immedi- 
ately before  serving  each  customer. 

7.  Every  barber  shop  shall  be  well  ventilated  and  provided 
with  hot  and  cold  water. 


262  PUBLIC  HEALTH  MEASURES. 

8.  No  barber  shop  shall  be  used  as  a  sleeping  room. 

9.  A  copy  of  this  article  shall  be  posted  in  plain  view  in 
every  barber  shop. 

Section  II.  Provides  for  a  fine  of  ten  dollars  for  each 
violation. 

There  are  a  number  of  things  in  this  ordinance  that  have 
no  relation  to  the  prevention  of  syphilis,  but  it  includes  the 
most  important  items.  Whenever  such  a  provision  can  be 
enforced,  it  would  be  advisable  to  provide  that  each  barber 
should  be  subject  to  a  physical  examination  by  the  health 
officer  at  stated  intervals,  and  in  those  cities  where  the 
Wassermanu  reaction  is  performed  by  the  city  laboratory 
this  test  should  be  included  in  the  examination. 

Soda  Fountains. — The  experiment  of  Gastou  and 
Comandon,  already  quoted  in  a  previous  chapter,  indicates 
that  syphilitic  infection  may  remain  on  drinking  glasses 
for  a  considerable  period  of  time.  There  are  so  many  chancres 
of  the  lip  acquired  innocently  and  without  any  knowledge 
of  a  possible  source  of  infection  by  the  victim,  that  it  appears 
probable  that  many  of  them  are  due  to  the  use  of  drinking 
glasses  that  have  been  recently  used  by  syphilitics.  The 
common  drinking  cup  has  been  abolished  from  railroad 
trains,  most  schools  and  public  fountains,  but  the  soda-water 
fountain  for  the  most  part  continues  to  offend.  After  use 
by  one  customer  the  glass  is  given  a  hasty  rinsing  in  a  can 
of  dirty  water  under  the  counter,  and  the  glass  is  again 
filled  and  used  by  the  next  person.  Under  these  circum- 
stances it  is  perfectly  possible  for  syphilis  to  be  transmitted 
from  one  customer  to  the  next.  Such  fountains  should  be 
brought  under  public  health  supervision.  They  should  be 
compelled  to  boil  their  glasses  between  each  customer 
served,  or  to  use  paper  cups  that  may  be  destroyed  after 
use  by  a  single  customer.  For  similar  reasons  all  restaurants, 
particularly  those  belonging  to  the  quick-lunch  type,  should 
be  under  supervision  and  inspected  at  irregular  intervals. 
Not  only  glasses  but  silverware  should  be  boiled  after  each 
use. 

Minor  Operations. — All  persons  who  perform  minor  opera- 
tions should  be  licensed  by  the  board  of  health  and  should 


THE  CONTROL  OF   VENEREAL  DISEASES         263 

be  under  supervision.  In  this  category  may  be  included 
such  operations  as  tattooing  and  circumcision.  The  mixing 
of  pigment  with  saUva,  or  holding  the  needles  in  the  mouth 
should  be  absolutely  prohibited,  and  tattooers  should  be 
subject  to  inspection,  and  if  possible,  to  physical  examination. 

In  any  community  in  which  circumcision  is  performed  as  a 
rite  by  rabbis  or  other  persons  not  having  a  medical  training, 
such  persons  should  be  licensed  by  the  board  of  health  after 
an  examination  sufficient  in  scope  to  determine  whether  the 
applicant  can  perform  the  operation  with  a  proper  technic; 
and  a  license  should  be  refused  those  who  suck  the  wound 
and  commit  other  similar  barbarities. 

Midwives  are  already  under  supervision  in  most  cities, 
but  an  earnest  effort  should  be  made  to  instruct  these  women 
with  regard  to  the  methods  of  transmission  of  syphilis,  and 
the  danger  to  them  and  to  their  patients  in  neglecting  all 
possible  precautions  against  this  infection.  So  far  as  possible 
they  should  be  encouraged  to  use  rubber  gloves.  A  circular 
containing  this  and  other  information  should  be  sent  to  every 
midwife  by  the  health  department. 

Finally,  as  the  Health  Department  is  compelled  to  employ 
vaccinators  on  a  large  scale,  they  should  be  informed  of  the 
danger  of  transmission  of  syphilis  during  this  operation,  and 
should  be  trained  not  to  use  the  same  knife  or  other  scarifi- 
cator on  more  than  one  person  without  sterilization. 

In  conclusion  it  may  be  pointed  out  that  the  foregoing 
discussion  is  presented  merely  as  an  outline  of  the  method 
by  which  the  public  health  officer  may  approach  the  problem 
of  the  control  of  syphilis.  For  the  most  part,  details  have 
been  purposely  omitted.  Conditions  vary  so  much  in 
different  cities  that  a  perfectly  good  set  of  rules  for  one  city 
would  be  inappropriate  in  another,  and  without  long  experi- 
ence with  local  conditions  it  would  be  presumptuous  to 
attempt  to  formulate  the  exact  procedure  for  a  given  com- 
munity. 

While  trying  to  avoid  this  blunder,  it  appears  that  a  little 
more  specific  information  might  prove  acceptable.  Incor- 
porated in  the  appendix  will  be  found  the  details  of  the  pro- 
cedure adopted  in  the  United  States  army  for  the  control 


264  PUBLIC  HEALTH  MEASURES 

of  syphilis,  and  also  the  method  used  in  Rochester,  N.  Y. 
I  am  indebted  to  Dr.  George  W.  Goler,  the  health  officer  of 
Rochester,  both  for  sending  me  the  data  with  regard  to  this 
city,  and  for  permission  to  use  it  in  this  connection.  It  is 
hoped  that  the  material  so  presented  will  not  only  give  some 
practical  hints  as  to  methods  of  procedure,  but  will  serve  to 
convince  those  inclined  to  skepticism  that  the  measures 
advocated  in  this  chapter  are  not  purely  theoretical,  but  on 
the  contrary  have  been  and  therefore  can  be  profitably 
employed  in  the  control  of  syphilis. 

REFERENCES. 

1.  Karpas:  The  Psychopathology  of  Prostitution,  New  York  Med. 
Jour.,  1917,  cvi,  105. 

2.  Brandweiner:  Statistics  of  Venereal  Diseases,  Arch.  f.  Dermat.  u. 
Syph.,  1908,  xci,  9.  Abstract  in  Ann.  des  Maladies  Veneriennes,  1908, 
iii,  709. 

3.  Snow:  Occupations  and  the  Venereal  Diseases,  Jour.  Am.  Med., 
Assn.,  1915,  Ixv,  2054. 

4.  Venereal  Disease  in  Christiania,  British  Med.  Jour.,  November  25, 
1916,  ii,  734. 

5.  British  Med.  Jour.,  1916,  ii,  591. 

6.  Evans:  Municipal  Health  Officers  and  Venereal  Disease,  Am.  Jour. 
Public  Health,  1915,  v,  884. 

7.  Cabot,  Hugh:     Syphilis  and  Society,  Social  Hygiene,  1916,  ii,  347. 

8.  Stokes:  Hospital  Problems  of  Gonorrhea  and  Syphilis,  read  before 
American  Public  Health  Association,  October  25,  1915.  Abstract  in  Jour. 
Am.  Med.  Assn.,  1916,  Ixvii,  1960.  See  also.  The  In-patient  Hospital  in 
the  Control  and  Study  of  Syphilis,  Social  Hygiene,  1916,  ii,  207. 

9.  Post:  Notes  of  a  Conference  on  the  Medical  and  Social  Aspects  of 
Syphilis,  Boston  Med.  and  Surg.  Jour.,  1915,  clxxiii,  867.  Also  ibid.,  1915, 
clxxiii,   161. 

10.  White:    Statistics  of  Syphilis,  Jour.  Am.  Med.  Assn.,  1914,  Ixiii,  459. 

11.  Snow:  Public  Health  Measures  in  Relation  to  Venereal  Diseases, 
Jour.  Am.  Med.  Assn.,  1916,  Ixvi,  1003.  See  also  Weber:  The  Treatment 
of  Venereal  Diseases  in  General  Dispensaries  of  New  York  State,  Social 
Hygiene,  1917,  iii,  341.  Also  Barringer  and  Piatt:  A  Survey  of  Venereal 
Clinics  in  New  York  City,  ibid.,  1915,  i,  344. 

12.  Blaisdell:  The  Menace  of  Syphilis  of  Today  to  the  Family  of  To- 
morrow, Boston  Med.  and  Surg.  Jour.,  1916,  clxxv,  7. 


APPENDIX. 


TECHNIC   OF   WASSERMANN. 

Cell  Suspension. — Blood  from  a  normal  individual  may 
be  collected  in  small  flasks  filled  with  salt  solution  or  in  a 
graduated  centrifuge  tube  filled  with  citrate  solution.  Cen- 
trifuge and  wash  cells  thoroughly  (three  or  four  washings). 
At  the  last  washing,  pack  cells  by  running  centrifuge  for  a 
given  length  of  time  at  a  certain  speed,  so  that  cells  will 
always  be  packed  to  a  similar  density.  Pour  off  supernatant 
fluid.  Each  0.1  c.c.  of  packed  cells  will  make  2  c.c.  of  cell 
suspension  in  normal  salt  solution  (a  5  per  cent,  suspension) . 

Complement.  —  The  pooled  serum  of  several  guinea-pigs 
that  have  been  freshly  bled.  To  each  1  c.c.  of  serum  add 
1.5  c.c.  of  0.85  per  cent,  salt  solution,  making  a  40  per  cent, 
complement. 

Amboceptor.  —  The  serum  of  rabbits  that  have  been 
immunized  to  human  red  cells.  Rabbits  are  immunized 
by,  intravenous  injection  of  0.5  c.c,  1  c.c,  2  c.c,  3  c.c; 
washed  and  packed  human  red  cells  at  five  to  seven  days' 
interval.  The  last  injection  of  3  c.c.  may  have  to  be  repeated 
several  times.  When  the  preliminary  titration  shows  that 
the  rabbit's  serum  contains  sufficient  hemolysin  the  rabbit 
is  bled.  Human  amboceptor  is  more  difficult  to  prepare  than 
sheep  amboceptor,  and  is  never  of  as  high  a  titer  as  sheep 
amboceptor. 

Antigen. — A  normal  human  heart  is  obtained  from  a  recent 
necropsy.  This  is  washed  free  from  blood  and  all  fat  care- 
fully removed.  To  100  grams  of  finely  minced  heart  muscle 
add  1000  c.c.  of  absolute  alcohol  and  shake  continuously 
in  a  machine  for  twenty-four  hours.  Filter  and  keep  the 
alcoholic  extract  in  the  ice-box  in  well-stoppered  bottles. 
When  needed  for  use,  25  c.c.  of  this  extract  is  fortified  with 
cholesterin.     Add  100  mg.,  thus  making  solution  0.4  per 


266 


APPENDIX 


cent,  cholesterin.  Allow  this  to  stand  for  several  days  and 
filter.  This  antigen  is  kept  in  the  ice-box.  When  it  is  to 
be  used  it  is  diluted  with  9  parts  of  normal  salt  solution, 
making  a  1  to  10  solution  of  the  original  stock  antigen. 

Titration  of  Complement.  —  Each  complement  must  be 
titrated  before  use,  using  the  cell  suspension,  which  should 
not  vary  from  day  to  day,  and  an  old  amboceptor  which 
has  been  tested  often  previously  with  one  unit  of  a  known 
complement.  The  amboceptor  changes  in  titer  so  slowly 
that  for  all  intents  and  purposes  it  may  be  regarded  as  a  non- 
variable.  The  new  complement  is  therefore  titrated  against 
an  amboceptor  and  a  cell  suspension  which  do  not  vary  in 
strength,  as  follows: 


Tube. 

1 

2 

3 

4 

5 

6 

7 

8 

9 

C.c. 

C.c. 

C.c. 

C.c. 

C.c. 

C.c. 

C.c. 

C.c. 

C.c. 

Complement  .      .      . 

0.02 

0.03 

0.04 

0.05 

0.06 

0.07 

0.08 

0.09 

0.1 

Cell  suspension    . 

0.1 

0.1 

0.1 

0.1 

0.1 

0.1 

0.1 

0.1 

0.1 

Salt  solution  . 

1.18 

1.17 

1.16 

1.15 

1.14 

1.13 

1.12 

1.11 

1.1 

Amboceptor   . 

1  unit 

lunit 

1  unit 

1  unit 

1  unit 

1  unit 

1  unit 

1  unit 

1  unit 

Total  volume  in  each  tube  1.3  c.c.  Incubate  for  one  hour 
in  water-bath  at  37|°  C,  shaking  every  fifteen  minutes,  the 
unit  of  complement  being  the  last  tube  in  which  hemolysis 
is  complete.  If  complement  and  amboceptor  are  both  of 
normal  strength  this  should  be  tube  4,  making  0.05  c.c.  the 
unit  of  complement.  As  two  units  of  complement  and  ambo- 
ceptor are  used  in  the  Wassermann  reaction  the  amount  to 
be  used  in  the  actual  tests  would  therefore  be  0.1  c.c. 

Titration  of  Amboceptor. — Before  killing  the  rabbit  a  pre- 
liminary titration  is  made.  The  rabbit  is  bled  into  a  Wright 
capsule,  the  serum  inactivated  (heated  to  56°  C.  for  one- 
half  hour)  and  one  drop  of  this  serum  is  diluted  with  19 
drops  of  salt  solution.  One  drop  of  this  1  to  20  dilution 
should  give  complete  hemolysis  in  one  hour  when  mixed 
with  0.1  c.c.  cell  suspension  and  one  unit  of  complement. 
If  this  fails  the  rabbit  is  given  another  injection.  Otherwise 
the  animal  is  bled  and  the  serum  separated  and  inactivated. 
This  serum  is  then  placed  on  paper  (Schleich  and  Schull's 
No.  597  paper  is  used)  and  cut  in  pieces,  8  cm.  square. 


TECHNIC  OF   WASSERMANN 


267 


To  each  such  sheet,  1  to  1.33  c.c.  serum  is  added,  an  amount 
that  just  saturates  the  sheet,  leaving  no  excess.  These 
pieces  of  paper  are  dried  on  a  strip  of  unbleached  muslin 
by  an  electric  fan  and  constitute  the  amboceptor,  which  must 
then  be  accurately  titrated. 

A  complement  which  has  been  previously  standardized 
by  titrating  against  an  old  and  known  amboceptor  is  used. 
The  amboceptor  paper  is  cut  in  strips,  5  mm.  wide,  and 
various  lengths  of  this  width  are  titrated  against  the  known 
complement  as  follows : 


Tube. 

1 

2 

3 

4 

5 

Complement 
Amboceptor 
Cell  suspension. 
Salt  solution 

1  unit 
1x5  mm. 
0.1  c.c. 
q.  s.  ad  1.3 

1  unit 
I5  X  5  mm. 
0.1  c.c. 
c.c.  to  each 

1  unit 
2x5  mm. 
0.1  c.c. 
tube. 

1  unit 

2|  X  5  mm. 

0.1  c.c. 

1  unit 
3x5  mm. 
0.1  c.c. 

Incubate  one  hour  in  water-bath. 

Suppose  that  the  last  tube  in  which  hemolysis  is  complete 
is  tube  4.  Then  for  this  paper  a  piece  2|  x  5  mm.  is  the  unit, 
and  as  two  units  are  used  in  the  Wassermann  reaction,  a 
piece  5x5  mm.  would  be  used  in  each  tube  in  the  actual 
tests.  This  titration  must  be  repeated  several  times,  with 
different  complements,  before  a  new  amboceptor  is  used. 

Titration  of  the  Antigen. — ^Tests  for  hemolytic  power,  anti- 
genic power  and  anticomplementary  action  must  be  made. 
As  a  matter  of  fact,  having  never' found  an  antigen  prepared 
in  this  way  to  be  hemolytic,  this  test  is  confined  to  one  tube 
in  which  the  antigen  is  used  in  five  times  the  amount  used 
in  the  test,  with  cell  suspension  and  salt  solution.  No  hemo- 
lysis should  occur.  Should  the  antigen  be  hemolytic  alone 
it  must  be  discarded. 

Tests  for  Antigenic  Power. — A  known  positive  serum  is 
titrated  with  the  new  antigen  and  an  old  antigen  of  known 
strength  as  follows: 


Tube. 

1 

2 

3 

4 

5 

Positive  serum  . 
Complement 
Antigen  . 
Salt  solution 

0.1  c.c. 
2  units 
0.1  c.c. 
1.0  c.c. 

0.05  c.c. 
2  units 
0.1  c.c. 
1.0  c.c. 

0.025  c.c. 
2  units 
0.1  c.c. 
1.0  c.c. 

0.012  c.c. 
2  units 
0.1  c.c. 
1.0  c.c. 

0.006  c.c. 
2  units 
0.1  c.c. 
1.0  c.c. 

268 


APPENDIX 


Incubate  one-half  hour  in  water-bath  and  add  to  each 
tube  0.1  c.c.  cells  and  two  units  of  amboceptor.  Incubate 
one  hour,  shaking  every  fifteen  minutes,  and  read. 

An  antigen  to  be  usable  should  give  complete  fixation  in 
tube  2  at  least,  viz.,  with  half  the  amount  of  serum  to  be 
used  in  the  tests.  Most  cholesterinized  antigens  will  give  a 
double  plus  in  tube  3,  with  quarter  the  amount  to  be  used  in 
the  tests.  By  comparing  the  new  antigen  with  the  old  in  this 
titration,  and  discarding  antjgens  that  are  either  too  weak 
or  too  strong,  the  reaction  will  be  standardized.  That  is, 
an  antigen  of  the  same  strength  will  always  be  used. 

The  antigen  should  also  be  tested  with  a  known  negative 
serum.  Twice  as  much  antigen  as  is  used  in  the  tests  must 
give  a  negative  reaction  with  a  known  negative  serum. 

Anticomplementary  Test. — All  antigens  possess  to  a  greater 
or  less  extent  the  power  of  uniting  with  complement  even  in 
the  absence  of  a  positive  serum.  If  this  power  were  at  all 
marked,  the  antigen  would  obviously  be  unsafe  to  use,  as  it 
would  cause  false  positive  reactions.  The  extent  of  this  anti- 
complementary action  is  determined  as  follows: 

A  dilution  of  the  stock  antigen  is  made  with  salt  solution, 
1  to  5,  instead  of  the  customary  1  to  10  dilution,  and  this 
antigen  is  titrated. 


Tube. 

1 

2 

3 

4 

5 

Antigen  . 
Complement 
Salt  solution 

0.1  c.c. 
2  units 
0.9  c.c. 

0.2  c.c. 
2  units 
0.8  c.c. 

0.3  c.c. 
2  units 
0.7  c.c. 

0.4  c.c. 
2  units 
0.6  c.c. 

0.5  c.c. 
2  units 
0.5  c.c. 

Incubate  in  water-bath  for  one-half  hour  and  add  to  each 
tube  two  units  of  amboceptor  and  one  unit  of  cell  suspension 
(0.1  c.c).  Incubate  for  one  hour,  shaking  every  fifteen 
minutes.  Should  hemolysis  be  complete  in  all  tubes  the 
antigen  is  not  anticomplementary  in  ten  times  the  amount 
used  in  the  test.  A  good  antigen  should  fulfil  this  require- 
ment. 

Performance  of  the  Test. — ^All  sera  used  are  inactivated  by 
heating  to  56°  C.  for  one-half  hour.     Two  tubes  are  used  for 


TECHNIC  OF   WASSERMANN  269 

each  test,  the  front  tube  being  the  test  proper  and  the  back 
tube  an  anticomplementary  control  to  show  that  the  serum 
alone  without  antigen  cannot  fix  complement.  Should  this 
back  tube  be  positive  the  test  must,  of  course,  be  thrown  out. 
Each  day  the  tests  are  made  a  known  positive  serum  and  a 
known  negative  serum  must  be  included  as  controls.  These 
must  be  positive  and  negative  respectively  or  the  tests  are 
valueless.  The  manner  in  which  the  tests  are  set  up  is  indi- 
cated as  follows: 

1 

Unknown, 
Back  tube.  c.c. 

Serum  to  be  tested     .      .      .      .     0 .  15 
Complement  (2  units)      .      .      .      0.1 
Salt  solution 0.9 

Front  tube.  1 

Serum  to  be  tested     .      .      .      .0.1 
Complement  (2  units)      .      .      .      0.1 

Antigen 0.1 

Salt  solution 0.9 

Incubate  for  one-half  hour  and  add  to  every  tube,  both 
front  and  back,  two  units  of  amboceptor  and  1  unit  cell 
suspension  (0.1  c.c).  Incubate  for  one  hour,  shaking  every 
fifteen  minutes.  Then  remove  from  the  water-bath  and 
read  the  reactions. 

Formerly  it  was  customary  to  keep  tubes  in  the  ice-box 
overnight  and  make  final  readings  then.  This  practice  has 
been  discontinued  because  it  is  believed  that  the  reaction 
obtained  by  reading  immediately  after  incubation  is  more 
accurate  than  the  later  ice-box  reading,  and  also  because  it 
saves  at  least  twelve  hours  in  getting  out  reports. 

Reading.  The  reaction  is  read  on  a  two-plus  basis. 
That  is: 

+  +  =  Complete  inhibition.     No  hemolysis. 

-(-  =  50  per  cent,  inhibition  or  more;  50  per  cent,  or  more  of  the 
cells  remain, 
-j —   =  Some  inhibition  but  less  than  50  per  cent.     Less  than  50 
per  cent,  of  the  cells  remain. 
—  =  No  inhibition.     Complete  hemolysis. 


2 
Known 
positive, 

CO. 

3 

Known 

negative, 

c.c. 

0.15 

0.15 

0.1 

0.1 

0.9 

0.9 

2 

3 

0.1 

0.1 

0.1 

0.1 

0.1 

0.1 

0.9 

0.9 

270  APPENDIX 

LAW  OF  THE  STATE  OF  MISSOURI  FOR  THE  REGULATION 
OF  THE  PRACTICE  OF  MEDICINE  AND  SURGERY. 

"Section  5. — Any  person  practising  medicine  or  surgery 
in  this  State,  and  any  person  attempting  to  treat  the  sick 
or  others  afflicted  with  bodily  or  mental  infirmities,  and  any 
person  representing  or  advertising  himself  by  any  means 
or  through  any  medium  whatsoever,  or  in  any  manner 
whatsoever,  so  as  to  indicate  that  he  is  authorized  to  or  does 
practice  medicine  or  surgery  in  this  State,  or  that  he  is 
authorized  to  do  or  does  treat  the  sick  or  others  afflicted 
with  bodily  or  mental  infirmities,  without  a  license  from  the 
State  Board  of  Health,  as  provided  in  this  act,  shall  be 
deemed  guilty  of  a  misdemeanor  and  punished  by  a  fine  of 
not  less  than  $50  nor  more  than  $500,  or  by  imprisonment  in 
the  county  jail  for  a  period  of  not  less  than  thirty  days  nor 
more  than  one  year,  or  by  both  such  fine  and  imprisonment 
for  each  and  every  offence.  Any  person  filing  or  attempting 
to  file  as  his  own  a  license  of  another,  or  a  forged  affidavit  of 
identification,  shall  be  guilty  of  a  felony,  and  upon  convic- 
tion thereof  shall  be  subject  to  such  fine  and  imprisonment 
as  are  made  and  provided  by  the  statutes  of  this  State  for 
the  crime  of  forgery  in  the  second  degree."  This  law  was 
upheld  by  the  Supreme  Court  of  Missouri  rendered  in  the 
October  term  of  1910. 

The  following  bill  has  been  recommended  by  the  Massa- 
chusetts State  Department  of  Health : 

"Section  1. — It  shall  be  unlawful  for  any  person,  firm  or 
corporation  to  sell,  furnish,  give  away  or  deliver  any  drugs, 
medicines  or  other  substances  to  be  used  for  the  cure  or 
alleviation  of  gonorrhea,  syphilis  or  other  venereal  disease 
except  upon  the  written  order  of  a  manufacturer  or  jobber 
in  drugs,  wholesale  druggist,  registered  pharmacist  actively 
engaged  in  business  as  such,  physician  registered  under  the 
laws  of  this  Commonwealth  or  an  incorporated  hospital 
through  its  superintendent  or  official  in  immediate  charge 
or  upon  the  written  prescription  of  a  physician  registered 
under  the  laws  of  this  Commonwealth,  bearing  his  legal 
signature  and  his  office  address. 

"  The  prescription  when  filled  shall  show  the  date  of  filling 


SALE  OF  QUACK  REMEDIES  271 

and  the  legal  signature  of  the  person  filling  it  written  across 
the  face  of  the  prescription,  and  shall  be  retained  on  file  by 
the  druggist  filling  it  for  a  period  of  at  least  two  years.  No 
order  or  prescription  shall  be  received  for  filling  or  filled  more 
than  fourteen  days  after  its  date  of  issue,  as  indicated  thereon. 

"  The  prescription  shall  not  again  be  filled,  nor  shall  a  copy 
of  the  same  be  made  except  for  the  purpose  of  record  by  the 
pharmacist  filling  the  same,  and  it  shall  at  all  times  be  open 
to  inspection  by  the  officers  of  the  State  Department  of 
Health,  the  Board  of  Registration  in  Pharmacy,  the  Board  of 
Registration  in  Medicine,  and  the  authorized  agents  of  said 
department  and  boards. 

"Section  2. — ^Any  person  who  for  the  purpose  of  evading 
or  assisting  in  the  evasion  of  any  provision  of  the  act  shall 
falsely  represent  that  he  is  a  manufacturer  or  a  jobber  in 
drugs,  wholesale  druggist,  registered  pharmacist  or  registered 
physician  or  superintendent  or  other  official  immediately  in 
charge  of  any  incorporated  hospital,  or  who,  not  being  a 
registered  physician,  makes  or  alters  a  prescription  or  written 
order  for  any  drug,  medicines  or  other  substances  to  be  used 
for  the  cure  or  alleviation  of  gonorrhea  or  syphilis  or  other 
venereal  diseases,  or  knowingly  issues  or  utters  a  prescription 
or  written  order  falsely  made  or  altered,  shall  be  deemed 
guilty  of  violation  of  this  act. " 

Section  3  provides  that  any  violation  of  this  act  shall  be 
punishable  by  a  fine  of  not  less  than  $5  for  a  first  offence, 
not  less  than  $100  for  a  second  offence,  and  by  fine  and 
imprisonment  for  not  less  than  thirty  nor  more  than  ninety 
days  for  any  subsequent  offence, 

WESTERN  AUSTRALIA  (ANNO  SEXTO), 
GEORGII  QUINTI  REGIS,  XXII. 


No.  55  of  1915. 
AN  ACT  TO  amend  the  Health  Act,  1911-12. 

(Assented  to,  8th  December,  1915.) 

Be  it  enacted  by  the  King's  Most  Excellent  Majesty,  by 
and  with  the  advice  and  consent  of  the  Legislative  Council 
and  Legislative  Assembly  of  Western   Australia,   in  this 


272  APPENDIX 

present  Parliament  assembled,  and  by  the  authority  of  the 
same,  as  follows: 

1.  This  Act  may  be  cited  as  the  Health  Act  Amendment 
Act,  1915,  and  shall  be  read  and  construed  as  one  with  the 
Health  Act,  1911  (hereinafter  called  the  principal  x\ct),  and 
this  Act  and  the  Health  Act,  1911-12,  may  be  cited  together 
as  the  Health  Act,  1911-15. 

2.  Section  three  of  the  principal  Act  is  hereby  amended 
by  inserting  in  its  appropriate  place  the  following  definition : 

"Venereal  disease"  means  and  includes  gonorrhea,  syphilis 
(including  congenital  syphilis),  soft  chancre,  venereal  warts 
and  granuloma. 

3.  The  following  Part  is  hereby  inserted  after  Part  IX 
of  the  principal  Act,  that  is  to  say: 

Part  IX.— A. 

VENEREAL  DISEASES  AND  DISORDERS 

AFFECTING  THE  GENERATIVE 

ORGANS. 

242a  (1)  No  persons  other  than  a  medical  practitioner, 
or  a  person  acting  under  the  direct  instructions  of  such  a 
practitioner,  shall  attend  upon  or  prescribe  for  any  person 
suffering  from  any  venereal  disease  for  the  purpose  of  curing, 
alleviating  or  treating  of  such  disease. 

Penalty :  Fifty  pounds,  or  six  months'  imprisonment  with 
hard  labor. 

(2)  The  preceding  subsection  shall  not  apply  to  a  registered 
pharmaceutical  chemist  who  dispenses  to  the  patient  of  a 
medical  practitioner  the  prescription  of  such  practitioner 
or  to  a  registered  pharmaceutical  chemist  who  sells  or  any 
person  who,  under  a  permit  in  writing  from  the  Commis- 
sioner (which  permit  the  Commissioner  is  hereby  empowered 
to  grant)  sells  to  any  person  any  patent  or  proprietary 
medicine  (as  defined  in  section  one  hundred  and  eighty- 
seven  of  this  Act)  for  the  cure  or  alleviation  of  any  venereal 
disease,  from  which  such  person  is  suffering:  Provided 
always  that  such  medicine  is  one  that  has  been  approved 
by  the  Commissioner  as  fit  to  be  sold  for  the  cure  or  allevia- 
tion of  such  disease. 


VENEREAL  DISEASES  IN   WESTERN  AUSTRALIA     273 

Nor  shall  the  preceding  subsection  apply  to  the  sale  by  a 
registered  pharmaceutical  chemist  in  the  ordinary  course 
of  business  of  any  drug,  not  being  a  patent  or  proprietary 
medicine  which  has  not  been  approved  as  aforesaid,  and  not 
being  prescribed  by  him  for  the  cure  or  alleviation  of  any 
venereal  disease. 

Provided  that  a  permit  as  aforesaid  shall  not  be  granted 
to  any  other  person  other  than  a  pharmaceutical  chemist 
unless  no  pharmaceutical  chemist  carries  on  business  within 
10  miles  of  the  place  of  business  of  such  person. 

242  &  (1)  Every  person  suffering  from  any  venereal 
disease  shall,  within  three  days  of  his  becoming  aware  or 
suspecting  that  he  is  so  suffering,  consult  a  medical  practi- 
tioner thereon  and  place  himself  under  treatment  by  such 
practitioner. 

Penalty :  Twenty  pounds. 

(2)  On  any  prosecution  under  this  section  it  shall  be  a 
defence  if  the  defendant  shall  prove: 

(i)  That  he  never  was,  within  the  period  of  three  days, 
within  twenty  miles  of  a  medical  practitioner;  and 

(ii)  That  he  did  within  such  period  consult  such  a  practi- 
tioner by  letter,  and  has  followed,  so  far  as  possible,  any 
advice  given  by  the  practitioner. 

Provided  that  such  proof  shall  afford  no  defence  if  it 
appears  that  at  any  time  before  the  complaint  was  laid  the 
condition  set  out  in  paragraph  (i)  hereof  has  ceased  to  apply 
to  the  defendant,  and  he  has  not  thereupon,  personally, 
consulted  and  placed  himself  under  treatment  by  a  medical 
practitioner. 

242c  (1)  Every  person  suffering  from  a  venereal  disease 
who  has  consulted  and  placed  himself  under  treatment  by  a 
medical  practitioner  shall  (until  he  has  received  a  certificate 
of  cure)  personally  attend  or  cause  himself  to  be  attended 
by  a  medical  practitioner  for  the  purpose  of  treatment  and 
advice  at  least  once  in  every  four  weeks  and  shall  follow, 
so  far  as  possible,  the  advice  given  by  any  such  practitioner. 

Penalty:  Twenty  pounds. 

(2)  If  any  such  person  shall  at  any  time  decide  to  change 
his  medical  adviser,  or  if  the  medical  adviser  of  such  person 
18 


274  APPENDIX 

shall  die,  or  for  any  reason  be  unable  or  unwilling  to  attend 
him  further,  then  such  person  shall  forthwith  consult  and 
place  himself  under  the  treatment  of  another  medical  practi- 
tioner, and  immediately  after  doing  so  shall  inform  his  new 
adviser  of  the  name  and  address  of  his  last  previous  adviser, 
and  the  medical  adviser  so  informed  shall  thereupon  send  a 
notification  in  the  prescribed  form  of  the  change  made  by 
the  patient  to  such  previous  adviser,  if  such  adviser  be  living 
and  in  the  State. 

Penalty:  Five  pounds. 

2^2d.  Every  medical  practitioner  shall  forthwith  give 
notice  to  the  Commissioner  in  the  prescribed  form  upon 
becoming  aware  that  any  person  attended  or  treated  by  him 
is  suffering  from  any  venereal  disease  in  an  infectious  stage. 
The  notice  shall  state  age  and  sex  of  the  patient  and  the 
nature  of  the  disease,  but  shall  omit  the  patient's  name 
and  address. 

Penalty :  Five  pounds. 

242e.  If  any  patient  who  has  been  attended  or  treated 
by  a  medical  practitioner  for  a  venereal  disease  in  an  infec- 
tious stage  shall  fail  to  consult  or  attend  such  practitioner 
for  a  period  of  six  weeks,  and  the  practitioner  shall  not  within 
that  period  have  received  from  another  practitioner  a  notice 
that  the  patient  has  changed  his  medical  adviser,  then  such 
first-mentioned  practitioner  shall  send  to  the  Commissioner, 
in  the  prescribed  form,  a  notice  of  the  facts,  stating  the 
name  and  address  of  the  patient. 

Penalty:  Five  pounds. 

242/.  Every  medical  practitioner  who  attends  or  advises 
any  patient  for  or  in  respect  of  any  venereal  disease  in  an 
infectious  stage  from  which  the  patient  is  suffering,  shall, 
by  written  notice  delivered  to  the  patient,  direct  such 
patient's  attention  to  the  contagious  character  of  the  disease, 
and  to  the  legal  consequences  of  infecting  others,  and  shall 
by  such  notice  warn  the  patient  against  contracting  any 
marriage  until  he  is  certified  as  cured. 

Penalty:  Five  pounds. 

242^.  When  any  such  patient  as  aforesaid  shall  become 
cured  of  the  disease,  any  medical  practitioner  shall,  on  being 


VENEREAL  DISEASES  IN   WESTERN  AUSTRALIA     275 

satisfied  of  the  fact,  give  such  patient  a  certificate  of  cure 
in  the  prescribed  form. 

242/i.  The  Commissioner  shall  conduct  free  of  charge 
bacteriological  or  other  examination  which  is  required  by 
any  medical  practitioner  who  has  notified  the  Commissioner 
under  Section  242rf  that  he  is  attending  or  treating  a  person 
suffering  from  venereal  disease. 

242i  (1)  When  any  person  under  the  age  of  sixteen  years 
is  or  becomes  liable  under  this  part  of  this  Act  to  do  or 
submit  to  any  act,  matter,  or  thing,  any  parent  or  guardian 
of  such  person,  who  knows  that  such  person  is  so  liable, 
shall  exercise  his  authority  and  use  his  best  endeavors  to 
compel  or  induce  such  person  to  do  or  submit  to  such  act, 
matter,  or  things  as  aforesaid. 

Penalty:  Ten  pounds. 

(2)  Any  parent  or  guardian  of  any  such  person  as  afore- 
said who  knows  that  such  person  has  failed  to  comply  with 
any  provision  of  this  Act  with  which  he  ought  to  have  com- 
plied, shall  report  the  fact  to  the  Commissioner. 

Penalty:  Ten  pounds. 

242j  (1)  Whenever  the  Commissioner  has  received  a 
signed  statement,  in  which  shall  be  set  forth  the  full  name 
and  address  of  the  informant,  stating  that  any  person  is 
suffering  from  venereal  disease,  and  whenever  the  Commis- 
sioner has  reason  to  believe  that  such  person  is  suffering 
from  such  disease,  he  may  give  notice,  in  writing,  to  such 
person  requiring  him  to  consult  a  medical  practitioner,  and 
to  produce  to  the  satisfaction  of  the  Commissioner,  within  a 
time  to  be  specified  in  the  notice,  a  certificate  of  such  medical 
practitioner  that  such  person  is  or  is  not  sufl^ering  from  the 
disease,  and  if  such  certificate  is  not  produced  within  the 
time  stated  in  such  notice,  or  if  the  Commissioner  be  not 
satisfied  with  such  certificate  he  may,  by  warrant  under 
his  hand,  authorize  any  medical  officer  of  health  or  any  two 
medical  practitioners  to  examine  such  person  to  ascertain 
whether  such  person  is  suffering  from  such  disease,  and  the 
said  officer  or  practitioners  shall  have  power  to  examine 
the  person  accordingly,  and  shall  report  the  result  of  his  or 
their  examination  to  the  Commissioner  in  writing. 


276  APPENDIX 

Provided  that  where  the  person  to  be  examined  is  a  female, 
and  the  examination  is  to  be  by  two  medical  practitioners, 
one  of  such  practitioners  shall,  if  so  desired  by  the  person 
to  be  examined,  be  a  female  medical  practitioner,  if  able 
and  willing  to  act,  and  within  twenty  miles  of  the  place  where 
the  examination  is  to  be  made. 

(2)  If  the  report  discloses  that  the  person  is  suffering  from 
any  venereal  disease  in  an  infectious  stage  and  is  in  the 
opinion  of  the  Commissioner  likely,  unless  detained,  to  infect 
other  persons,  the  Commissioner  may,  by  warrant  under  his 
hand  in  the  prescribed  form  and  directed  to  the  prescribed 
persons,  order  the  person  to  be  apprehended,  and  to  be 
detained  for  any  period  not  exceeding  two  weeks  in  any 
hospital  or  any  other  place,  and  the  Commissioner  may  by 
such  warrant  order  any  bacteriological  and  other  examina- 
tions and  investigations  to  be  made  of  and  in  respect  of  such 
person. 

(3)  If  after  such  detention  it  shall  appear  to  the  Commis- 
sioner that  the  person  is  suffering  from  any  venereal  disease 
in  an  infectious  condition,  and  that  further  detention  is 
necessary  to  the  interests  of  the  public,  and  so  reports  to  the 
Governor,  then  it  shall  be  lawful  for  the  Governor,  at  any 
time  and  from  time  to  time  on  the  recommendation  of  the 
Commissioner,  to  issue  his  warrant  in  such  form  and  directed 
to  such  persons  as  he  shall  think  fit,  authorizing  and  requiring 
the  apprehension  of  such  person  and  the  detention  of  such 
person  in  such  place  for  such  time  as  the  Governor  may 
think  fit,  and  the  Governor  may  by  any  such  warrant  direct 
that  such  person  shall  be  subject  to  any  treatment  and 
examination  which  the  Governor  may,  on  the  recommenda- 
tion of  the  Commissioner,  think  necessary  in  the  circum- 
stances. 

(4)  When  any  person  is  subject  to  detention  under  this 
section  he  may  from  time  to  time  apply  in  writing  to  a  judge 
of  the  Supreme  Court  or  a  resident  or  police  magistrate  in 
the  district  in  which  he  is  detained  to  be  examined  by  two 
medical  practitioners,  and  thereupon  such  judge  or  magis- 
trate shall  by  order  direct  any  two  or  more  medical  practi- 
tioners named  in  the  order,  one  of  whom  shall  be  nominated 
by  the  patient  or  some  person  on  his  behalf,  to  examine  such . 


VENEREAL  DISEASES  IN  WESTERN  AUSTRALIA     277 

person  accordingly  and  report  the  result  of  the  examination 
to  the  judge  or  magistrate,  and  every  officer  or  authority 
in  whose  custody  the  person  is  shall  permit  the  examination. 
If  it  appears  from  such  report  that  all  the  medical  practi- 
tioners are  unanimously  of  opinion  that  the  person  is  cured 
or  is  free  from  venereal  disease,  or  if  such  report  disclosed 
that  the  person  is  suffering  from  venereal  disease  in  an  infec- 
tious stage,  but  the  Commissioner  fails  to  satisfy  the  judge 
or  magistrate  that  the  person  would  be  likely  to  infect  others 
unless  detained,  then  the  judge  or  magistrate  shall  order  the 
release  of  such  person;  who  shall  be  liberated  from  detention 
accordingly;  provided  that  no  application  shall  be  made 
by  a  person  so  detained  within  six  calendar  months  of  a 
prior  application  having  been  made  by  such  person. 

(5)  When  any  person  is  subject  to  examination  or  deten- 
tion under  the  provisions  of  this  section,  and  is  found  not 
to  be  suffering  from  venereal  disease,  or  to  be  suffering  from 
venereal  disease,  but  not  in  an  infectious  stage,  or  to  be 
suffering  from  venereal  disease  in  an  infectious  stage,  but  not 
likely  to  infect  others,  such  person  shall  be  entitled  as  of 
right  to  inspect  any  written  statement  made  to  the  Com- 
missioner under  Subsection  (1)  of  this  section,  and  to  have 
a  verified  copy  of  every  such  statement. 

(6)  This  section  shall  apply  to  any  person  undergoing 
imprisonment,  but  except  in  so  far  as  is  necessary  in  order 
to  carry  into  effect  the  provisions  of  this  section,  the  sentence 
of  imprisonment  shall  not  be  interfered  with;  provided  that 
the  period  of  any  detention  suffered  hereunder  shall  be 
reckoned'  as  part  of  the  term  of  imprisonment.  If  the  person 
still  remains  liable  to  serve  any  portion  of  the  term  of  impris- 
onment at  the  termination  of  the  detention  hereunder,  the 
Minister  may  issue  his  order  to  any  police  officer,  directing 
him  to  convey  the  person  to  the  gaol  or  prison  where  such 
person  is  liable  to  complete  the  sentence. 

(7)  Every  warrant  issued  hereunder  may  authorize  the 
use  of  such  force  as  may  be  necessary  to  carry  it  into  complete 
effect,  and  shall  have  effect  according  to  its  tenor,  and  all 
police  officers  shall  on  sight  of  the  warrant  aid  and  assist 
in  its  execution  in  so  far  as  they  may  be  requested  so  to  do 
by  any  person  to  whom  the  warrant  is  directed. 


278  APPENDIX 

(8)  Any  person  who  contravenes  any  provision  of  this 
section  by  act  or  omission  or  obstructs  the  carrying  into 
effect  of  any  warrant  or  order  issued  thereunder  or  refuses 
to  do  or  submit  to  anything  which  such  person  is  by  this 
section  or  any  such  warrant  or  order,  required  to  do  or 
submit  to,  shall  be  guilty  of  an  offence  against  this  Act. 

Penalty:  Twenty  pounds. 

242A;.  No  person  shall  knowingly  infect  any  other  person 
with  a  venereal  disease  or  knowingly  do  or  suffer  any  act 
likely  to  lead  to  the  infection  of  any  other  person  with  such  a 
disease. 

Penalty:  Fifty  pounds  or  imprisonment  with  hard  labor 
for  six  months. 

242/  (1)  The  persons  having  the  management  or  control 
of  any  hospital  which  has  received  in  any  financial  year  a 
subsidy  from  the  State  shall  make  effective  provision  for 
the  examination  and  treatment  free  of  charge,  in  accordance 
with  regulations  made  by  the  Governor  (pursuant  to  the 
power  which  is  hereby  conferred  upon  him)  of  such  persons 
or  classes  of  persons  suffering  from  venereal  disease  as  the 
Governor  may  by  such  regulations  declare  fit  to  be  treated 
at  or  by  such  hospital. 

In  case  default  is  made  in  compliance  with  this  subsection 
the  Colonial  Treasurer  may  withhold  from  such  hospital 
the  whole  or  any  portion  of  any  subsidy  which  would  be 
payable  thereto  during  the  next  financial  year. 

(2)  Every  medical  practitioner  in  receipt  of  any  salary 
from  the  State  shall  examine  and  treat  free  of  charge  to  such 
person  any  person  suffering  from  venereal  disease  who  shall 
apply  to  him  for  examination  and  treatment. 

And  the  Commissioner  shall  pay  a  reasonable  renumera- 
tion  for  such  examination  and  treatment,  and  shall  be  liable 
to  be  sued  for  such  renumeration  in  any  court  of  competent 
jurisdiction. 

Any  medical  practitioner  who  neglects  or  refuses  to  examine 
or  treat  any  person  as  provided  by  this  subsection,  shall  be 
liable  to  a  penalty  not  exceeding  five  pounds. 

242m.  All  proceedings  under  sections  242a,  2426,  242c, 
242c?,  242e,  242/,  242i,  242j,  242A-,  in  any  court  shall  be  heard 


VENEREAL  DISEASES  IN  WESTERN  AUSTRALIA     279 

in  camera ;  and  it  shall  be  unlawful  to  publish  in  any  newspaper 
a  report  of  any  such  proceedings. 

Penalty:  For  a  first  offence,  One  hundred  pounds,  or 
imprisonment  with  or  without  hard  labor  for  not  exceeding 
six  months;  for  any  subsequent  offence  five  hundred  pounds, 
or  imprisonment  with  or  without  hard  labor  for  not  exceeding 
twelve  months. 

242?!  (1)  No  person  shall  publish  any  statement  which 
is  intended  by  such  person  or  any  other  person  to  promote 
the  sale  of  any  article  as  a  medicine,  instrument,  or  appliance, 
for  the  alleviation  or  cure  of  any  venereal  disease  or  disease 
affecting  the  generative  organs  or  functions,  or  of  sexual 
impotence,  or  of  any  complaint  or  infirmity  arising  from  or 
relating  to  sexual  intercourse  or  of  female  or  menstrual 
irregularities. 

(2)  Any  person  who — 

(a)  So  affixes  or  inscribes  any  statement  or  anything 
whatsoever  that  it  is  visible  to  persons  being  in  or  passing 
along  any  street,  road,  highway,  railway  or  public  place;  or 

(6)  Delivers  or  offers  or  exliibits  any  statement  to  any 
person  being  in  or  passing  along  any  street,  road,  highway, 
pathway,  public  place  or  public  conveyance;  or 

(c)  Throws  any  statement  down  the  area  or  into  the  yard, 
garden  or  enclosure  of  any  house;  or 

(d)  Exhibits  any  statement  to  public  view  in  any  house, 
shop  or  place ;  or 

(e)  Prints  or  publishes  any  statement  in  any  newspaper;  or 
(/)  Sells,  offers,  or  shows  or  sends  by  post  any  statement 

to  any  person,  shall  be  deemed  to  have  published  that 
statement. 

(3)  The  word  "statement"  includes  any  document,  book 
or  paper  containing  any  statement. 

(4)  Books,  documents  and  papers  published  in  good  faith 
for  the  advancement  of  medical  or  surgical  science  are  exempt 
from  the  provisions  of  this  section. 

(5)  Any  contravention  of  this  section  shall  be  an  offence 
against  this  Act. 

(6)  Before  any  proceedings  are  taken  under  this  section 
against  any  newspaper  proprietor,  printer,  or  publisher  for 
printing  or  publishing  any  statement  in  a  newspaper,  the 


280  APPENDIX 

Commissioner  shall  notify  the  proprietor,  printer,  and  pub- 
lisher of  such  newspaper  that  the  publication  of  the  matter 
complained  of  is  an  infringement  of  this  part  of  this  Act; 
and  such  proprietor,  printer,  and  publisher  shall  not  be 
liable  to  prosecution  for  an  offence  against  this  section  except 
in  respect  of  an  offence  of  the  same  or  a  similar  nature  after 
such  notification. 

242o.  Every  person  employed  in  the  administration  of  this 
part  of  this  Act  shall  preserve  secrecy  with  regard  to  all 
matters  that  may  come  to  his  knowledge  in  the  course  of 
such  employment,  and  shall  not  communicate  any  such 
matter  to  any  other  person  except  in  the  performance  of  his 
duties  under  this  Act. 

Penalty:  One  hundred  pounds. 

242]^.  So  far  as  personal  service  of  any  notice  is  required 
under  the  provisions  of  this  part  of  this  Act,  such  service 
shall  be  effected  by  an  officer  of  public  health. 

4.  The  following  section  is  hereby  added  to  the  principal 
Act.   • 

301.  All  courts  and  magistrates  shall  take  judicial  notice 
of  all  by-laws  and  regulations  made  under  this  Act. 

5.  All  copies  of  the  Health  Act,  1911-12,  hereinafter 
printed  by  the  Government  Printer  shall  be  printed  as 
amended  by  this  Act  under  the  supervision  of  the  Clerk  of 
Parliaments,  and  all  necessary  references  to  this  Act  made  in 
the  margin,  and  in  any  such  reprint  the  short  title  shall  be 
the  Health  Act,  1911-15. 

THE  CONTROL  OF  SYPHILIS  IN  THE  ARMY. 

This  order  advises  continence ;  directs  that  the  incontinent 
must  take  the  prescribed  prophylactic ;  prescribes  an  inspec- 
tion to  detect  concealed  cases,  and  directs  that  all  cases  be 
treated. 

[G.  O.  17. 
General  Orders,  1  WAR    DEPARTMENT, 

No.  17.  /  Washington,  May  31,  1912. 

1.  It  is  enjoined  upon  all  officers  serving  with  troops  to  do 
their  utmost  to  encourage  healthful  exercises  and  physical 
recreation  and  to  supply  opportunities  for  cleanly  social  and 
interesting  mental  occupations  for  the  men  under  their  com- 


THE  CONTROL  OF  SYPHILIS  IN  THE  ARMY      281 

mand;  to  take  advantage  of  favorable  opportunities  to  point 
out,  particularly  to  the  younger  men,  the  inevitable  misery 
and  disaster  which  follow  upon  intemperance  and  moral 
uncleanliness,  and  that  venereal  disease,  which  is  almost  sure 
to  follow  licentious  living,  is  never  a  trivial  affair.  Although 
the  chief  obligation  and  responsibility  for  the  instruction  of 
soldiers  in  these  matters  rests  upon  company  officers,  the 
medical  officers  should  cooperate  by  occasional  lectures  or 
other  instruction  upon  the  subject  of  sexual  physiology  and 
hygiene  and  the  dangers  of  venereal  infection. 

2.  Commanding  officers  will  require  that  men  who  expose 
themselves  to  the  danger  of  contracting  venereal  disease  shall 
at  once  upon  their  return  to  camp  or  garrison  report  to  the 
hospital  or  dispensary  for  the  application  of  such  cleansing 
and  prophylaxis  as  may  be  prescribed  by  the  Surgeon-General. 
Any  soldier  who  fails  to  comply  with  such  instructions,  if 
found  to  be  suffering  from  a  venereal  affection,  shall  be 
brought  to  trial  by  court-martial  for  neglect  of  duty. 

3.  Commanding  officers  will  require  a  medical  officer, 
accompanied  by  the  company  or  detachment  commander,  to 
make  a  thorough  physical  inspection  twice  in  each  month  of 
all  the  enlisted  men  (except  married  men  of  good  character) 
of  each  organization  belonging  to  or  attached  to  the  com- 
mand. These  inspections  will  be  made  at  times  not  known 
beforehand  to  the  men  and  preferably  immediately  after  a 
formation.  The  dates  on  which  the  physical  inspections  of  the 
various  organizations  are  made  will  be  noted  on  the  monthly 
sanitary  reports. 

At  these  inspections  a  careful  examination  of  the  feet  and 
footwear  and  of  the  condition  of  personal  cleanliness  of  the 
men  will  be  made,  as  well  as  careful  observation  for  the  detec- 
tion of  venereal  diseases. 

Cases  of  the  latter  will  be  promptly  subjected  to  treatment, 
but  not  necessarily  excused  from  duty  unless,  in  the  opinion 
of  the  sm-geon,  deemed  desirable.  They  will  be  made  of 
record  in  the  medical  reports  in  any  case.  A  list  of  those 
diseased  but  doing  duty  will  be  kept  both  by  the  company  or 
detachment  commander  and  the  surgeon,  and  the  infected 
men  will  be  required  to  report  to  a  medical  officer  for  system- 
atic treatment  until  cured.     While  in  the  infectious  stages 


282  APPENDIX 

the  men  should  be  confined  strictly  to  the  limits  of  the  post. 
When  a  venereal  case,  whether  or  not  on  sick  report,  is  trans- 
ferred to  another  command,  the  surgeon  will  send  a  transfer 
slip  giving  a  brief  history  of  the  case. 

4.  All  instructions  from  the  War  Department  prohibiting 
the  publication  in  printed  or  other  orders  of  instructions  pre- 
scribing examinations  having  in  view  the  detection  of  venereal 
diseases  among  enlisted  men,  heretofore  issued,  are  recalled. 

[1915426,  A.  G.  O.] 

By  Order  of  the  Secretary  of  War: 

LEONARD  WOOD, 

Major-General,  Chief  of  Staff. 
Official: 

W.  p.  HALL, 

The  Adjutant-General. 

The  following  are  the  usual  directions  for  carrying  out  the 
system  of  venereal  prophylaxis  directed  by  par.  2,  G.  O.  17, 
W.  D.,  1912. 

A  suitable,  easily  accessible  room  in  the  hospital  (or  dis- 
pensary) at  each  post  will  be  selected  for  this  purpose,  which 
should  be  provided  with  a  good  light  and  such  medical 
supplies,  basins,  and  other  equipment  as  may  be  necessary. 
A  competent,  properly  instructed  man  of  the  Hospital  Corps, 
or  more  when  necessary,  will  be  on  duty  there  between 
retreat  and  reveille,  and  will  be  within  call  at  other  hours. 

The  procedure  in  the  case  of  men  reporting  for  treatment 
will  be  as  follows: 

1.  The  name,  rank,  and  organization  of  the  soldier,  with 
the  day  and  hour  of  treatment  should  be  entered  for  record 
on  a  card  furnished  for  the  purpose,  which  will  afterward 
be  examined  and  authenticated  by  the  initials  of  a  medical 
officer.  These  records  should  be  regarded  as  confidential 
and  should  be  kept  in  a  secure  place  and  not  shown  to 
unauthorized  persons  or  except  upon  proper  authority.  They 
will  not  be  preserved  longer  than  three  months. 

2.  The  genital  organs  will  be  thoroughly  washed  with  soap 
and  warm  water. 

3.  An  injection  will  be  made  into  the  urethra  of  4  c.c.  of 
the  standard  solution  of  2  per  cent,  protargol  dissolved  in 


THE  CONTROL  OF  SYPHILIS  IN  THE  ARMY      283 

glycerin  15  parts,  water  85  parts.  This  should  be  retained  in 
the  urethra  for  three  minutes.  In  individual  cases  when  the 
protargol  solution  is  found  to  produce  an  irritating  effect, 
a  20  per  cent,  solution  of  argyrol  may  be  used.  Other  solu- 
tions or  modifications  of  these  solutions  will  not  be  used  for 
routine  administration. 

4.  The  entire  penis  will  be  rubbed  with  calomel  ointment 
(30  per  cent,  in  benzoated  lard),  care  being  taken  that  the 
folds  of  the  prepuce  and  about  the  frenum  are  thoroughly 
covered.  If  any  pimples  or  abrasions  exist  about  the  scrotum 
or  the  pubic  region,  these  should  also  receive  an  application  of 
the  ointment. 

The  parts  should  then  be  wrapped  in  a  napkin  of  soft 
paper  furnished  for  the  purpose,  in  order  to  protect  the 
clothing. 

Stoppage  of  pay  while  absent  from  duty  on  account  of 
venereal  disease.  This  measure  as  well  as  possible  trial  by 
court-martial,  for  disobedience  of  orders  in  the  case  of  those 
men  who  develop  venereal  disease  but  have  not  taken  the 
prophylactic  as  ordered,  are  intended  to  compel  men  to  take 
the  prophylactic  after  exposure. 

[G.  O.  31.] 
General  Orders,  \  WAR   DEPARTMENT, 

No.  31.  j  Washington,  September  12,  1912. 

1.  The  following  extract  from  "An  Act  making  appropria- 
tion for  the  support  of  the  Army  for  the  fiscal  year  ending 
June  thirtieth,  nineteen  hundred  and  thirteen,  and  for  other 
purposes,"  approved  August  24,  1912,  is  published  for  the 
information  and  guidance  of  all  concerned: 

Provided,  That  no  officer  or  enlisted  man  in  active  service, 
who  shall  be  absent  from  duty  on  account  of  disease  resulting 
from  his  own  intemperate  use  of  drugs,  or  alcoholic  liquors, 
or  other  misconduct,  shall  receive  pay  for  the  period  of  such 
absence  from  any  part  of  the  appropriation  in  this  Act  for  the 
pay  of  officers  or  enlisted  men,  the  time  so  absent  and  the 
cause  thereof  to  be  ascertained  under  such  procedure  and 
regulations  as  may  be  prescribed  by  the  Secretary  of  War. 

2.  Absence  from  duty  because  of  the  intemperate  use  of 
drugs  or  alcoholic  liquors,  or  because  of  incapacity  resulting 


284  APPENDIX 

from  venereal  diseases  not  contracted  in  line  of  duty,  is 
within  the  purview  of  the  statute  quoted  above;  and  any 
officer  or  enlisted  man  who,  on  or  after  August  24,  1912,  has 
been  absent  or  may  hereafter  be  absent  from  duty  for  any  such 
cause  or  causes,  is  not  entitled  to  pay,  as  distinguished  from 
allowances,  for  the  period  of  such  absence. 

3.  Whenever  an  officer  or  enlisted  man  is  absent  from  duty 
due  to  causes  within  the  purview  of  the  statute  quoted  above, 
the  company  commander  will  state  in  the  "Daily  Sick 
Report"  his  opinion  to  that  effect  by  noting  "No;  G.  O.  31, 
1912, "  in  the  column  headed  "  In  line  of  duty"  of  the  " Com- 
pany Officer's  Report,"  and  the  surgeon  will  in  like  manner 
record  his  opinion  in  the  column  "  In  line  of  duty "  of  the 
"Medical  Officer's  Report."  Notice  that  such  an  entry  has 
been  made  will  at  once  be  brought  to  the  attention  of  the 
officer  or  enlisted  man  concerned  by  the  company  commander. 

When  the  company  commander  and  the  surgeon  are  in 
accord,  the  finding,  if  approved  by  the  commanding  officer, 
shall  be  final.  Should  the  company  commander  and  the 
surgeon  disagree,  or  should  the  commanding  officer  dissent, 
the  latter  will  call  a  board  of  officers  of  not  less  than  two 
members,  one  of  whom  shall  be  a  medical  officer,  to  report 
upon  and  make  recommendations  in  the  case.  Approval 
by  the  commanding  officer  of  the  findings  of  this  board  shall 
be  final;  but  if  the  commanding  officer  disapprove  the  findings 
of  the  board  the  proceedings  will  be  forwarded  for  the  action 
of  the  next  higher  authority. 

In  the  case  of  a  company  commander  or  of  an  officer  or 
enlisted  man  not  carried  upon  the  rolls  of  a  company  the 
duties  hereinbefore  required  of  the  company  commander  will 
be  performed  by  the  next  superior  officer  under  whose  com- 
mand or  direction  the  officer  or  enlisted  man  concerned  may 
be  serving. 

The  terms  "company"  and  "company  commander"  will 
be  understood  as  including  a  troop,  battery,  band,  or  detach- 
ment, and  the  commanding  officer  thereof. 

4.  When  it  has  been  determined  in  the  manner  herein- 
before prescribed  that  an  officer  has  been  absent  from  duty 
due  to  causes  within  the  purview  of  the  statute  quoted  above, 
the  proper  commanding  officer  will  forward  to  the  division 


THE  CONTROL  OF  SYPHILIS  IN  THE  ARMY      285 

commander  a  report  showing  the  inclusive  dates  of  the 
absence  and  the  cause  thereof.  This  report  will  be  forwarded 
to  the  Adjutant-General  of  the  Army  for  transmission  to 
the  Chief  of  the  Quartermaster's  Corps,  who  will  take  the 
necessary  action  looking  to  stoppage  of  pay  for  the  period 
of  absence  from  duty.  In  cases  arising  in  the  Philippines 
Division,  the  division  commander,  at  the  time  of  the  sending 
of  the  original  report  to  the  Adjutant-General,  will  transmit 
a  copy  thereof  to  the  Chief  Quartermaster,  Philippines 
Division,  who  will  take  the  necessary  action  toward  securing 
the  proper  stoppage  of  pay. 

When  it  has  been  determined  in  the  manner  hereinbefore 
prescribed  that  an  enlisted  man  has  been  absent  from  duty 
due  to  causes  within  the  purview  of  the  statute  quoted  above, 
the  proper  commanding  officer  will  make  notation  to  that 
effect  on  the  pay-rolls  or  on  final  statements  giving  the 
inclusive  dates  of  the  absence,  and  the  paymaster  will  make 
deduction  of  pay  for  such  period.  If  it  is  impracticable  to 
determine  within  the  month  in  which  the  absence  from  duty 
occurs  that  such  absence  was  due  to  causes  which  should 
deprive  the  soldier  of  his  pay,  he  will  not  be  permitted  to  draw 
pay  for  that  or  any  subsequent  month  until  the  cause  of  the 
absence  from  duty  has  been  determined. 

[1945857,  A   G.  O.] 

By  Order  of  the  Secretary  of  War: 

LEONARD  WOOD, 

Major-General,  Chief  of  Staff. 
Official  : 

GEO.  ANDREWS, 

The  Adjutant-General. 


Directions  in  regard  to  treatment  of  syphilis 

ClECULAR  1 


[Cir.  No.  14.] 
WAR   DEPARTMENT, 
-^  ?  Office  of  Surgeon-General, 

^°-  ■^*-   J  Washington,  August  3,  1914. 

The  following  instructions  concerning  the  use  of  salvarsan 
and  neosalvarsan  are  published  for  the  information  and  guid- 
ance of  medical  officers,  superseding  all  previous  circulars  on 
this  subject: 


286  APPENDIX 

Indications. — Salvarsan  or  neosalvarsan  is  indicated  (1)  for 
the  rapid  control  of  the  manifestations  of  syphilis,  both 
clinical  and  serological.  For  this  purpose  one  or  more  intra- 
venous injections  of  the  drug  are  to  be  given,  the  dose,  interval 
and  number  of  injections  to  be  determined  by  the  indications 
presented  in  each  individual  case.  It  should  be  recognized 
that  the  object  of  this  treatment  is  to  secure  prompt  ameliora- 
tion of  the  symptoms  only,  and  that  further  treatment  will  be 
necessary  in  order  to  attain  more  permanent  results.  (2) 
For  the  radical  cure  of  syphilis  in  the  primary  stage,  in  com- 
bination with  an  intensive  course  of  treatment  with  mercury. 
The  possibility  of  attaining  such  a  cure  is  now  well  established. 
The  highest  percentage  of  successful  results  is  obtained  in 
cases  treated  in  the  primary  stage  before  the  appearance  of  the 
Wassermann  reaction;  in  such  cases  the  diagnosis  must  neces- 
sarily rest  upon  discovery  of  the  parasite  in  the  initial  lesion. 
The  combined  treatment  consists  of  from  three  to  six  intra- 
venous injections  of  salvarsan,  at  intervals  of  from  one  to 
two  weeks,  combined  with  an  intensive  course  of  mercurial 
treatment  by  inunction  or  intramuscular  injection,  or  by 
both  methods,  continued  for  a  period  of  from  one  to  two 
months.  Salvarsan  rather  than  neosalvarsan  should  be  used, 
and  ascending  doses  should  be  given,  beginning  with  one-half 
of  the  maximum  dose.  The  administration  of  mercury  must 
be  pushed  until  the  physiological  limit  is  reached.  Only 
patients  in  good  health  in  other  respects,  and  whose  kidneys 
are  known  to  be  normal,  are  suitable  for  the  intensive  treat- 
ment. The  preparation  of  mercury  most  used  in  this  country 
for  intramuscular  injection  is  the  basic  salicylate.  A  10  per 
cent,  suspension  is  made  in  liquid  petrolatum;  0.6  to  1  c.c.  of 
the  suspension  is  to  be  given  at  least  once  a  week. 

Contra-indications. — ^Aside  from  the  ordinary  contra-indi- 
cations,  such  as  severe  organic  disease  due  to  other  causes, 
two  possible  complications  must  be  kept  in  mind — nervous 
relapse  and  uremia.  Both  these  conditions  may  occur,  under 
certain  circumstances,  after  treatment,  during  the  active 
secondary  stage,  and  cases  in  this  stage  must  be  treated  with 
special  caution.  Nervous  relapse  may  occur  after  inadequate 
treatment  in  cases  where  the  nervous  system  is  already 
infected.    In  such  cases  one  or  two  injections  of  salvarsan, 


THE  CONTROL  OF  SYPHILIS  IN  THE  ARMY      287 

not  followed  up  by  other  treatment,  may  do  more  harm  than 
good,  and  a  thorough  combined  course  of  treatment  should 
be  instituted,  or  mercury  alone  used. 

Recent  literature  records  a  number  of  deaths  following  the 
administration  of  salvarsan  and  neosalvarsan.  A  certain  pro- 
portion of  these  deaths  presented  identical  symptoms;  these 
occurred  in  the  active  secondary  stage  of  the  disease,  two  or 
three  days  after  the  second  injection  of  the  remedies.  The 
symptoms  presented  by  these  cases  resembled  those  of  uremia. 
In  our  service,  during  the  past  three  and  one-half  years,  four 
such  cases  have  occurred,  one  after  the  administration  of  sal- 
varsan and  three  after  the  administration  of  neosalvarsan. 
During  the  period  referred  to  over  31,000  doses  of  the  drugs 
have  been  issued.  Autopsies  and  histological  examinations 
in  three  of  the  fatal  cases  showed  an  intense  acute  nephritis. 
The  condition  of  the  kidneys  prior  to  the  administration  of  the 
drug  was  not  known.  While  the  exact  explanation  of  the 
cause  of  these  deaths  is  in  doubt,  the  lesion  of  the  kidneys 
deserves  consideration. 

It  is  directed  that,  in  all  cases  in  which  it  is  contemplated 
to  administer  salvarsan  or  neosalvarsan,  the  urine  of  the 
patient  be  examined,  and  should  any  case  show  evidence  of 
kidney  involvement,  that  these  drugs  be  withheld  or  used  in 
small  doses.  A  urinary  examination  will  also  be  made  after 
each  administration  of  salvarsan  or  neosalvarsan.  Intense 
headache  after  the  administration  of  salvarsan  is  a  danger 
signal.  To  counteract  this  complication,  in  addition  to  the 
usual  measures,  adrenalin  in  one-half-milligram  doses  admin- 
istered subcutaneously  has  been  recommended. 

Salvarsan  versus  Neosalvarsan. — Neosalvarsan  weighs  one 
and  one-half  times  as  much  as  salvarsan  for  the  equivalent 
content  of  arsenic,  and  the  ratio  of  dosage  is  therefore  3  to  2 ; 
e.  (J.,  0.9  gm.  neosalvarsan  is  equivalent  to  0.6  gm.  salvarsan. 
Salvarsan,  however,  is  clinically  more  effective  in  propor- 
tionate doses  than  neosalvarsan  and  should  be  used  when 
intensive  effect  is  desired,  as  in  attempting  a  rapid  cure. 
During  the  year  1913  over  1000  more  doses  of  neosalvarsan 
were  used  than  of  salvarsan,  but,  while  no  restriction  has  been 
placed  on  the  choice  of  these  drugs,  neosalvarsan  should  not 
be  used  to  the  exclusion  of  salvarsan  simply  because  it  is 
easier  to  handle. 


APPENDIX 

Method  of  Preparation. — Saharsan. — ^Salvarsan  is  put  up  in 
sealed  ampoules  filled  with  a  neutral  gas  to  prevent  oxidation, 
and  only  intact  ampoules  should  be  used.  Salvarsan,  when  dis- 
solved in  water  or  salt  solution,  forms  an  acid  salt  which  is 
too  caustic  for  use;  on  neutralizing  it  with  sodium  hydroxide, 
the  soluble  acid  salt  is  changed  into  a  neutral  base  which  is 
insoluble ;  further  addition  of  sodium  hydroxide  converts  the 
insoluble  neutral  base  into  an  alkaline  sodium  salt  which  is 
soluble;  0.8-0.9  c.c.  of  a  4  per  cent,  sodium  hydroxide  solution 
is  required  for  each  0.1  gm.  of  powder — i.  e.,  if  the  dose  is  0.5 
gm.,  4-4.5  c.c.  of  the  4  per  cent,  solution  of  sodium  hydroxide 
will  be  required.  The  end-point  is  the  complete  solution  of  the 
precipitate ;  care  should  be  taken  not  to  go  beyond  this  point, 
as  an  excess  of  alkalinity  is  liable  to  cause  a  thrombosis.  To 
avoid  this,  a  small  amount  of  precipitate  may  be  left  undis- 
solved. 

The  solution  of  salvarsan,  prepared  as  described  above,  is 
added  to  60-150  c.c.  of  an  0.85  per  cent,  salt  solution  and 
administered  at  room  or  body  temperature.  The  salt  solution 
should  be  made  with  freshly  distilled  water,  sterilized  imme- 
diately, and  kept  well  stoppered  until  used.  Salt  solution 
made  of  stale  distilled  water  contains  many  dead  organisms 
after  sterilization  and  produces  severe  reactions. 

Neosalvarsan. — Neosalvarsan  dissolves  readily  in  water  and 
forms  a  neutral  solution  ready  for  use.  It  is  more  unstable 
than  salvarsan  and  should  be  given  immediately  after 
preparation  at  room  teviperature.  It  may  be  given  in  about 
150  c.c.  of  a  0.4  per  cent,  salt  solution  with  the  standard 
apparatus,  or  in  concentrated  solution,  0.9  gm.  in  20  c.c.  of 
distilled  water  with  a  syringe. 

Intravenous  Injections. — These  are  easily  given  with  the 
standard  apparatus,  which  should  contain  a  light  plug  of  ab- 
sorbent cotton  in  the  neck  to  filter  out  undissolved  particles, 
etc.  The  injection  tube  and  needle  should  be  filled  with  salt 
solution  before  the  prepared  solution  is  poured  into  the  reser- 
voir, so  that  salt  solution  only  will  escape  into  the  tissues 
if  the  vein  is  missed  on  the  first  trial.  In  most  cases  it 
is  unnecessary  to  expose  a  vein  by  incision,  which  incision  is 
justifiable  only  when  absolutely  necessary. 


THE  CONTROL  OF  SYPHILIS  IN  THE  ARMY      289 

Intramuscular  Injections. — These  should  be  used  only  when 
intravenous  injections  are  impracticable.  The  alkaline  solu- 
tion of  salvarsan  is  diluted  to  about  20  c.c.  with  sterilized 
water,  and  10  c.c.  are  injected  into  each  buttock.  Or  the 
powder  may  be  suspended  in  2-3  c.c.  of  sterile  liquid  petro- 
latum which  is  similarly  injected.  For  the  latter  method  the 
syringe  must  be  absolutely  dry  and  should  be  lubricated  with 
oil  or  the  piston  will  bind.  Neosalvarsan  may  be  given  in 
the  same  way,  either  in  solution  in  20  c.c.  of  sterile  water  or 
in  suspension  in  sterile  liquid  petrolatum.  The  painfulness 
and  uncertainty  of  absorption  of  intramuscular  injections  are 
objections  to  this  method. 

Plan  of  Treatment. — In  suitable  early  cases,  radical  cure  in 
a  short  time  should  be  attempted  on  account  of  the  advan- 
tages of  a  successful  result.  In  other  cases  the  chronic  inter- 
mittent treatment  by  inunction  or  injection  of  mercury  should 
be  carried  out,  using  salvarsan  when  necessary  to  control 
symptoms  and  to  reduce  a  positive  Wassermann  reaction. 

Observation  of  Cases. — In  the  absence  of  symptoms  the 
Wassermann  reaction  is  the  only  reliable  index  of  the  infec- 
tion; after  treatment  has  been  suspended,  Wassermann  reac- 
tions should  be  made  at  intervals  of  one  or  two  months.  If 
they  continue  negative  at  the  end  of  a  year  a  provocative 
reaction  should  be  made.  If  possible,  a  luetin  reaction  and 
examination  of  the  spinal  fluid  should  also  be  made  before 
the  case  is  closed.  A  certain  proportion  of  cases  are  "  Wasser- 
mann-fast" — that  is,  the  Wassermann  reaction  is  uninflu- 
enced by  treatment;  these  cases  usually  have  aortic  lesions 
or  involvement  of  the  nervous  system.  In  such  cases  exami- 
nation of  the  spinal  fluid  should  especially  be  made. 

The  information  contained  in  well-kept  syphilitic  registers 
has  been  found  to  be  of  great  scientific  and  practical  value, 
and  it  is  enjoined  that  every  efi^ort  be  made  to  follow  cases 
closely  and  to  record  important  data. 

W.  C.  GORGAS, 

Surgeon-General,  United  States  Army. 

The  Syphilitic  Register  which  accompanies  every  soldier  from 
the  time  the  diagnosis  of  syphilis  is  made  until  he  is  cured  or 
is  separated  from  the  service  by  death,  discharge  or  desertion. 

19 


290  APPENDIX 


(FRONT) 


Date. 
Race. 


FORM    78 

Medical  Depaktment,  U.  S.  A. 

(Revised  Nov.  24,  1913) 

SYPHILITIC  REGISTER. 


IN  THE  CASE   OF 

(Surname)  (Given  name) 

(Rank)  (Co.)  (Regiment  or  Staff  Corps) 

BIRTH. 


DATES   OF  ENLISTMENTS. 


FINAL  DISPOSITION  OF  CASE. 

Deserted 

Died 

TRANSMITTAL  OF  REGISTER  TO   SURGEON-GENERAL. 
Date                                                                          

Signature 

THE  CONTROL  OF  SYPHILIS   IN   THE  ARMY      291 

(BACK) 
INSTRUCTIONS. 

1.  This  Register  will  be  kept  in  the  case  of  every  soldier,  and  of  every 
general  prisoner,  who  has  syphilis.  It  will  be  begun  at  the  first  station 
where  the  diagnosis  is  made,  and  will  be  continued  until  the  patient  is  cured 
or  permanently  leaves  the  service. 

2.  A  case  is  considered  cured  when  the  following  conditions  have  been 
fulfilled: 

(a)  No  treatment  for  one  year  during  which  there  have  been  no  symp- 
toms, no  positive  Wassermann  reactions  and  several  negative  ones. 

(6)  At  the  end  of  the  year  a  negative  provocative  Wassermann  reaction 
and  a  negative  luetin  test. 

3.  The  initial  diagnosis,  origin  of  infection,  and  principal  lesions,  with 
the  dates  of  same,  will  be  noted  on  page  2.  Other  important  manifesta- 
tions and  memoranda  worthy  of  remark  will  be  noted  under  "Progress  of 
Case." 

4.  The  serum  tests  to  determine  the  status  of  the  infection  will  be  recorded 
by  the  dates  and  places  thereof  under  "Serum  Reactions,"  indicating  in  the 
"Result"  column  the  nature  of  the  reactions  by  the  symbols  -f-  +,  -|-,  -\ — , 
and  — . 

.   5.  The  medicines  used  and  methods  of  administration  will  be  noted  by 
successive  entries  in  the  appropriate  columns  under  "Treatment." 

6.  The  stations  where  the  patient  serves  or  is  confined  during  the  period 
of  observation  and  his  movements  from  one  to  another  will  be  recorded  on 
next  to  the  last  page. 

7.  When  the  patient  is  sent  from  one  station  or  command  to  another  the 
Register  will  be  sent  to  the  surgeon  of  the  new  station  or  command  in  time 
to  arrive  with  or  before  the  man,  if  possible.  If  the  Register  does  not 
arrive  within  a  reasonable  time  the  surgeon  will  so  adAdse  the  surgeon  of 
the  old  station  or  command,  and  meanwhile  will  start  a  new  Register 
until  the  original  one  is  received. 

8.  Each  medical  officer  will  initial  the  entries  made  by  his  direction. 
He  will  sign  in  the  appropriate  columns  the  prescribed  record  of  treatments. 

9.  On  cure,  or  on  termination  of  service  or  confinement,  without  reen- 
listment,  the  Register  will  be  forwarded  to  the  Surgeon-General. 

10.  When  the  case  is  finally  disposed  of  by  discharge  on  certificate  of 
disability,  a  full  statement  of  the  causes  of  the  disability  for  which  the 
patient  was  discharged,  and  of  his  present  condition  due  to  the  syphilitic 
infection,  will  be  recorded  under  "Progress  of  Case." 

The  intermediate  sheets  of  this  register  contain  appro- 
priate blanks  for  the  date  and  result  of  all  serum  reactions 
made,  and  also  accurate  details  of  all  treatment  given, 
including  place  and  date  received,  character  and  amount 
of  drug  and  method  of  administration.  Other  sheets  provide 
for  notes  on  the  progress  of  the  case. 


292  APPENDIX 

METHODS  EMPLOYED  BY  SOME  CITIES. 

Methods  of  publicity  employed  by  the  city  of  Rochester, 
N.  Y.,  and  sent  through  the  courtesy  of  the  Health  Officer, 
Dr.  George  W.  Goler.  A  booklet  on  Syphilis,  Gonorrhea  and 
Gonorrheal  Ophthalmia,  which  is  too  long  to  reproduce  here, 
is  circulated  among  physicians  and  patients. 

The  following  advertisement  is  inserted  in  the  daily  papers : 

RESIDENTS  OF  ROCHESTER  avoid  quack 
doctors,  quack  dentists  and  patent  medi- 
cines. Your  time  and  money  will  be  wasted; 
you  will  not  be  cured  and  your  health  may  be 
ruined  by  the  use  of  them;  free  confidential 
advice  concerning  your  health  at  the  Health 
Bureau,  Chestnut  and  James  Streets,  Mondays 
and  Thursdays,  3  to  4  and  Monday,  7  to  8  p.m. 

The  following  statement  is  used  as  a  poster  in  suitable 
places : 

VENEREAL  DISEASES! 

AVOID  QUACKS  AND  PATENT  MEDICINES! 
Your  Time  and  Money  Will  Be  Wasted. 
You  Will  Not  Be  Cured. 
Your  Health  May  Be  Ruined. 
Free  Confidential  Advice  Can  Be  Obtained  from 

THE  BUREAU  OF  HEALTH, 

Rochester,  N.  Y. 

On  Mondays,  3  to  4  and  7  to  8  p.m.    Thursdays,  3  to  4  p.m. 

Methods  of  notifying  the  patient  that  he  must  report  for 
treatment.  In  use  at  Rochester,  N.  Y.,  and  sent  through 
the  courtesy  of  the  Health  Officer,  Dr.  George  W.  Goler. 


METHODS  EMPLOYED  BY  SOME  CITIES  293 

HEALTH  BUREAU. 
Rochester,  N.  Y 


Please  call  at  the  Health  Bureau  Consultation 


on. 


George  W.  Goler,  M.D., 

Health  Officer. 


HEALTH  BUREAU. 


Unless  you  report  to  the  Health  Bureau  consultation  on 

we  will  ask  the  police  to  call 

upon  you. 

George  W.  Goler,  M.D., 

Health  Officer. 

ROCHESTER  HEALTH  BUREAU, 

CONSULTATION. 

Name 

Address Date 

You  are  required  to  report  on  the  last  date  named  on  the 

back  of  this  card. 

George  W.  Goler,  M.D., 

Health  Officer. 
HOURS. 
Mondays,  3-4  and  7-8  p.m. 
Thursdays,  3-4  p.m. 


294 


APPENDIX 


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296  APPENDIX 

Letter  sent  to  physicians  whose  patients  have  a  positive 
Wassermann: 

CITY  OF  ROCHESTER,  EXECUTIVE  DIVISION, 

health  bureau. 
Dear  Doctor: 

We  have  a  Wassermann  report  of 

which  is     .     .     +. 

It  is  our  observation  that  a  very  small  percentage  of 
patients  affected  with  syphilis  remain  under  treatment  long 
enough  to  prevent  them  from  becoming  a  danger  to  others 
and  a  menace  to  themselves,  and  that  they  are  thus  unable 
to  conduct  themselves  in  such  a  manner  as  not  to  expose 
other  persons  with  whom  they  may  be  associated  to  the 
danger  of  infection. 

It  is  for  these  reasons  that  the  Public  Health  Law  has 
given  us  power  to  control  such  persons.  Following  out  the 
provisions  of  that  law,  we  shall  require  from  you  a  report 
on  the  15th  and  30th  day  of  each  month,  stating  that  the 
within-named  patient  is  under  your  treatment.  If  the 
patient  goes  to  another  physician  a  similar  report  will  be  ' 
required  from  the  next  physician.  These  reports  are  to 
be  sent  until  the  patient  has  had  at  least  two  negative 
Wassermanns. 

Failing  to   receive   a  report,  we   shall,   without   further 
notice,  ask  the  police  to  secure  the  patient,  and  we  will 
proceed  against  the  patient  under  the  Public  Health  Law. 
Respectfully  yours, 

Health  Officer. 

Report  that  must  be  sent  by  the  physician  treating  the 
case,  to  show  that  treatment  is  still  being  given.  Sent 
through  the  courtesy  of  the  Health  Officer,  Dr.  George  W. 
Goler. 

Rochester,  N.  Y., 191 

This  is  to  certify  that 

is  still  under  my  care. 

(Signed) M.D. 


VENEREAL  PROPHYLAXIS  IN  CHICAGO  297 

VENEREAL  DISEASES:  REPORTS  OF  CASES  TO  THE 
DEPARTMENT  OF  HEALTH. 


AN  ORDINANCE 

Passed  by  the  City  Council  June  29,  1917,  Requiring  the 
Reporting  of  Venereal  Diseases. 

Be  it  Ordained  by  the  City  Council  of  the  City  of  Chicago. 

Section  1. — That  the  Chicago  code  of  1911  be  and  the 
same  is  hereby  amended  by  adding  thereto  the  following 
sections : 

1193a.  Venereal  Diseases. — Dangerous  to  Public  Health. — 
Syphilis,  gonorrhea  and  chancroid,  hereinafter  designated 
venereal  diseases,  are  hereby  recognized  and  declared  to  be 
contagious,  infectious,  communicable  and  dangerous  to  the 
Public  Health. 

11936.  Venereal  Diseases  to  he  Reported. — It  shall  be  the 
duty  of  every  licensed  physician,  of  every  superintendent  or 
manager  of  a  hospital  or  dispensary,  and  of  every  person 
who  gives  treatment  for  a  venereal  disease,  to  mail  to  the 
Department  of  Health  of  the  City  of  Chicago  a  card  supplied 
by  this  Department  stating  the  age,  sex,  color,  marital  con- 
dition and  occupation  of  such  diseased  person,  the  nature 
and  previous  duration  of  such  disease  and  the  probable 
origin;  such  card  to  be  mailed  within  tliree  days  after  the 
first  examination  of  such  diseased  person;  provided  that, 
except  as  hereinafter  required  the  name  and  address  of  such 
diseased  person  shall  not  be  reported  to  the  Department  of 
Health. 

1193c.  Persons  Afflicted  with  Venereal  Diseases  to  he  Given 
a  Circidar  of  Information. — It  shall  be  the  duty  of  every 
licensed  physician  and  of  every  other  person  who  treats  a 
person  afflicted  with  venereal  disease  to  give  to  such  person 
at  the  first  examination  a  circular  of  information  and  advice 
concerning  venereal  diseases  furnished  by  the  Department 


298  APPENDIX 

of  Health;  and  in  addition  to  give  to  such  diseased  person,  a 
copy  of  this  ordinance,  and  to  report  to  the  Health  Depart- 
ment that  such  diseased  person  has  received  the  two  docu- 
ments herein  specified. 

119Sd.  Change  of  Physician  to  be  Reported  by  Patient  to 
Physician  First  Consulted. — When  a  person  applies  to  a 
physician  or  other  person  for  treatment  of  a  venereal  disease, 
it  shall  be  the  duty  of  the  physician  or  person  consulted  to 
inquire  of  and  ascertain  from  the  person  seeking  treatment 
whether  such  person  has  theretofore  consulted  with  or  been 
treated  by  any  other  physicians  or  persons,  and  if  so  to 
ascertain  the  name  and  address  of  the  physician  or  person  last 
theretofore  consulted.  It  shall  be  the  duty  of  the  applicant 
for  treatment  to  furnish  this  information,  and  a  refusal  to  do  so, 
or  falsely  stating  the  name  and  address  of  such  physician  or 
person  consulted  shall  be  deemed  a  violation  of  this  ordinance. 
It  shall  be  the  duty  of  the  physician  or  person  consulted 
where  the  applicant  has  heretofore  received  treatment  to 
immediately  notify  by  mail  the  physician  or  person  last 
theretofore  treating  such  applicant  of  the  change  of  adviser; 
such  notification  to  be  made  upon  a  form  furnished  for  that 
purpose  by  the  Department  of  Health.  Should  the  physician 
or  person  previously  consulted  fail  to  receive  such  notice 
within  ten  days  after  the  last  appearance  of  such  venereally 
diseased  person  it  shall  be  the  duty  of  such  physician  to 
report  to  the  Health  Department  the  name  and  address  of 
such  venereally  diseased  person. 

1193e.  Protection  of  Others  from  Infection  by  Venereally 
Diseased  Persons. — Upon  receipt  of  a  report  of  a  case  of 
venereal  disease  it  shall  be  the  duty  of  the  Commissioner 
of  Health  to  institute  such  measures  for  the  protection  of 
other  persons  from  infection  by  such  venereally  diseased 
person  as  said  Commissioner  of  Health  is  already  empowered 
to  use  to  prevent  the  spread  of  other  contagious,  infectious  or 
communicable  diseases. 

1193/.  Reports  to  be  Confidential. — All  information  and 
reports  concerning  persons  infected  with  venereal  diseases 
shall  be  confidential  and  shall  be  inaccessible  to  the  public, 


VENEREAL  PROPHYLAXIS  IN  CHICAGO  299 

except  in  so  far  as  publicity  may  attend  the  performance  of 
the  duty  imposed  upon  the  Commissioner  of  Health  by 
Section  1193e  of  this  ordinance. 

1193^.  Parents  Responsible  for  the  Compliance^  of  Minors 
with  the  Requirements  of  Regulations.- — The  parents  of  minors 
acquiring  venereal  diseases  and  living  with  said  parents 
shall  be  legally  responsible  for  the  compliance  of  such  minors 
with  the  requirements  of  the  ordinance  relating  to  venereal 
diseases. 

1193/1.  Penalty. — Any  person  who  violates,  neglects  or 
refuses  to  comply  with  the  provisions  of  Sections  1193a, 
11936,  1193c,  1193(^,  1193e,  1193/ and  U93g  of  this  ordinance 
shall  be  fined  not  less  than  twenty-five  dollars  ($25.00)  nor 
more  than  one  hundred  dollars  ($100.00)  for  each  offence. 

Section  2. — This  ordinance  shall  take  effect  and  be  in 
force  from  and  after  its  passage  and  due  publication. 

Form  sent  to  physicians : 


CITY  OF  CHICAGO, 

DEPAETMENT   OF   HEALTH. 

November  26,  1917. 

Dear  Doctor: 

An  ordinance  passed  by  the  City  Council,  June  29,  1917, 
requires  that  venereal  diseases  be  reported  to  the  Depart- 
ment of  Health. 

Enclosed  find  a  circular  of  information  including,  on  page 
10,  a  copy  of  the  ordinance;  also  reporting  cards  and  blanks 
for  the  use  of  the  doctor  in  complying  with  the  ordinance. 
Yours  very  truly, 

John  Dill  Robertson,  M.D., 

Commissioner  of  Health. 


300  APPENDIX 

Form  on  which  physicians  report  cases: 

191. 

I  hereby  report  a  case  of . 


£  ft 

03  Q 

6 


(Syphilis,  Gonorrhea,  Chancroid) 

Age: Sex: Color: Married: 

Occupation : 

Date  of  Onset: 191 ..  . 

Probable  Origin : 

Have  you  given  patient  copy  of  venereal  disease  ordinance  and 

circular    of    information? Has    patient    been    treated    for 

this  disease  by  anyone  previous  to  his  call  on  you? Have 

you  notified  the  previous  adviser  of  the  patient's  change  to  you  for 

treatment? 

Signed M.D. 

Telephone Address 

191 


Department  of  Health, 

City  Hall,  Chicago. 
Dear  Sir: 

This  is  to  notify  you  that 

(Name) 

(Address) 

under  my  treatment  for  venereal  disease,  has  not  reported 
to  me  within  ten  days  of  the  time  agreed  upon,  and  that  I 
have  not  received  a  report  to  the  effect  that  he  has  placed 
himself  under  the  care  of  another  adviser. 
Respectfully, 

M.D. 

(Address) 


VENEREAL  PROPHYLAXIS  IN  CHICAGO  301 

191 

Dr 


Dear  Doctor: 

In  accordance  with  the  requirements  of  Section  1193d 
of  the  Municipal  Code  of  Chicago,  I  have  to  notify  you  that 


(Name) 
(Address) 

formerly  treated  by  you,  has  now  placed  himself  under  my 
care  and  treatment. 

Respectfully, 

M.D. 

• ■» 

(Address) 


INDEX  OF  AUTHORS. 


AcEVEDO,183 

Agato,  167 
Allen,  41 

Almkvist,  49,  129,  130 
Anderson,  73,  100 
AsMord,  186 
Assinder,  44 
D'Astros,  39 
Austin,  19,  72,  99 

B 

Baermann,  33 
Baetz,  87 
Barrett,  40 
Barringer,  252 
Barthelemy,  113 
Bayet,  38 
Behrmann,  168 
Bennie,  41 
Bergeron,  40,  68 
Berterelli,  119 
Bettman,  129,  131 
Blackfan,  72 
Blaisdell,  23,  254 
Blaschko,  35,  129,  158 
Boas,  74,  91 
Bonnet,  181 
Boudreau,  71,  100 
Brandweiner,  195,  215 
Breitenstein,  165 
Breslauer,  178 
Breton,  38,  39 
Broc,  34 
Brock,  34,  68 
Bronfenbrenner,  123 
Brooks,  19 
Browning,  44,  47,  96 
Bryan,  97 
Buba,  113 
Bubendorf,  39 
Bulkley,  54.  136,  148 


Buschke,  119 
Butte,  167,  182 

C 

Cabot,  202,  238 

Calmette,  39 

Cardier,  129 

Carle,  182 

Churchill,  72,  99 

Clarke,  46 

Coffin,  144 

Cohn,  168 

Colles,  118,  146 

Collie,  45 

Commandon,  122,  124,  262 

Commenge,  230 

Commisky,  83 

Condon,  166 

Cooper,  69,  99 

Corper,  70 

Costen,  57 

Cottle,  186 

Couvreur,  39 

Covisa,  129 

Cozanet,  129 

Craig,  80 

Cunningham,  46 

D 

Darling,  45,  50,  96 
Davidson,  185 
Davis,  48,  96 
Dawson,  76 
Dean,  37,  74 
Dechambre,  137 
Desault,  167 

Diday,  112,  138,  141,  145 
Doutrelepont,  115 
Downing,  18 
Dreyer,  118 
Durac,  145 


304 


INDEX  OF  AUTHORS 


E 

Ehrlich,  260 
Eitner,  123 
Elliott,  43 
Emerson,  53,  238 
Emery,  129 
Epstein,  36 
Erb,  36 
Exner,  187 


Fallopius,  166 

Falls,  83,  101 

Favre,  31 

Feistmantel,  183 

Feldhusen,  30 

Fell,  53,  59,  97 

Feulard,  113,  114 

Field,  55 

Fildes,  45,  84 

Finger,  113,  115,  118,  120 

Fischer,  46,  119 

Fisk  22 

Flexner,  224,  230 

Ford,  69 

Fordyce,  131 

Foucar,  76 

Fournier,  38,  112,  121,  136,  140, 

144,   148,   157,  204 
Fox,  87 

Freeland,  163,  165 
French,  41 

G 

Gastou,  122,  124,  262 
Gatewood,  58,  97 
Gaucher,  181,  182 
Generopitorozeff,  29 
Gerrish,  46 
Gerson,  181 
Goler,  264,  292 
Gottstein,  178 
Graham,  46 
Greeley,  53,  97 
Greenspan,  55 
Grouven,  115 
Guiard,  169 
Guyomarch,  35 

H 

Haberman,  144,  145 
Hahn,  149 


Haines,  74,  100 

Haller,  60,  97 

Hamill,  22 

Hammond,  63 

Havas,  129 

Hazen,  87,  131 

Hecht,  48,  96 

Heller,  36 

Hertmanni,  122 

Heuss,  129 

Hindman,  89 

Hochsinger,  145 

Hoffman,  116,  119,  125,  169 

Holbrook,  52,  97 

Holt,  72,  99 

Hooker,  97 

Hopkins,  123 

Hornon,  61,  97 

Hough,  51,  89,  97 

Hubert,  37 

Hugel,  177 

Hutchinson,  112,  124,  131,  163, 

165,  205 
Huxley,  218 


I 


IvEY,  52,  89 


Jakowlew,  129 
Jamison,  91 
Janeway,  64,  97 
Jeans,  147 
Jefferys,  32 
Johansson,  49 
Johnson,  73,  100 
Jones,  69,  99 
Joseph,  Max,  113,  169 
Jullien,  131 

K 

Knapp,  62 

Kneeland,  47,  53,  96,  215 
Koch,  177 
Kolmer,  66,  98 
Kramer,  71,  100 
Kromayer,  113 
Krumbhaar,  65 
Ktirner,  36 


Ladd,  66,  98 
Landouzy,  114 


INDEX  OF  AUTHORS 


305 


Landsteiner,  116,  118,  120,  123 

Lane,  129 

Langlebert,  112 

Lassar,  114 

Lawson,  81,  84 

Ledbetter,  185 

Leduc,  39 

Lee,  88 

Lenz,  19,  35 

Leonhard,  215 

Lepine,  68 

Leredde,  20 

LetuUe,  40,  68 

Levaditi,  119 

Levy-Bing,  172 

Levy-Valesi,  35 

Lippmann,  37,  74 

Livingston,  34 

Loeb,  169 

Losee,  84,  101 

Lucas,  73,  100 

Lynch,  89 

Lyons,  69,  99 

M 

Mackenzie,  43 

MacNeal,  57 

Magian,  129 

Maisonneuve,  172 

Major,  64,  97 

Manson,  43 

Marschalko,  162 

Marshall,  129 

Matas,  86 

Matson,  49,  96 

Mattauschek,  20 

Maxwell,  32 

McDonagh,  109 

McHatton,  86 

Mcllroy,  26,  43 

McKay,  75 

McLester,  64,  99 

McNeill,  48,  90 

Meirowsky,  48,  96 

Metchnikoff,    167,    169,    171,    173, 

180 
Michels,  184 
Mitchell,  51,  97 
Moller,  229 
Montgomery,  65 
Moore,  58,  83,  91,  97,  101 
Mott,  45 
Moulton,  75 
20 


Moyer,  164 
Mucha,  123 
Mueller,  129 
Mulzer,  116,  118,  120 
Miinchheimer,  148 
Munger,  80,  100 
Murrell,  85,  89 
Musser,  65,  98 

N 

Neisser,  116,  120,  122,  127,  173, 

184 
Neumann,  36 
Newcomb,  50,  96 
Newman,  113 
Nichols,  80,  120,  127,  137 
Nicholson,  72 
Noguchi,  123,  125 
Nonne,  131 


O 


Oberwarth,  36 
Osier,  18 
Ottenberg,  84 


Paine,  50,  96,  97 
Papee,  129 
Pasini,  119,  125 
Perichitch,  31 
Peterson,  59,  97 
Petit,  38 
Petroff,  69,  99 
PUcz,  20 

Le  Pileur,  144,  166 
Pinkus,  36,  49,  96 
Piper,  41 
Piatt,  252 
Pollitzer,  71,  100 
Pollock,  87 
Pontoppidan,  250 
Post,  250 
Preval,  168 
Prof  eta,  118,  146 
Puche,  158 
Pusey,  109 


Q 


QUALLS,  92 

Quillian,  86 


306 


INDEX  OF  AUTHORS 


R 

Rabinowitsch,  30,  75 
Raven,  146 
Raviart,  38 

Reasoner,  126,  137,  192 
Reiss,  129 
Renner,  148 
Reynolds,  189 
Richter,  168 
Ricord,  112,  140 
Riggs,  158,  187 
Ringenbach,  35 
Rodaeli,  119 
Rosenberger,  65,  97 
Rothschuh,  34 
Roux,  169,  171,  173 


S 


Salmon,  19 

Sandberg,  29 

Schaudinn,  119,  169 

Scheube,  32 

Scheuer,  29,  123,  148,  154 

Schroeder,  21,  34 

Seitz,  148 

Sessions,  75 

Shamberg,  126,  260 

Sicard,  35 

Siebert,  174,  185 

Skelton,  188 

Smith,  43 

Snow,  C.  G.,  69,  99 

Snow,  W.  F.,  54,  158,  196,  216 

Southard,  51,  96 

Spaulding,  48,  96 

Stengel,  19 

Stevenson,  27 

Stiles,  109 

Stokes,  250,  255 

Stromberg,  215 

Sullivan,  48,  96,  218 

Symmers,  54 


Tandler,  184 
Tarassewitch,  113,  115 
Tarnowski,  114 
Teissonniere,  39 
Thomas,  71,  100 


Toepfel,  118 
Tomasezewski,  115 
Torok,  38 

Tschistjakow,  113,  158 
Tschlenoff,  30 
Turner,  166 


U 

Uhlenhuth,  116,  118,  120 
Ustvedt,  236 


V 


Van  der  Hoof,  64 

Vedder,  51,  54,  69,  71,  80,  89,  97, 

99,  195 
Veeder,  146 
Verchere,  129 
Volpino,  119 
Von  Cassel,  36 
Von  Dliring-Pascha,  31 
Von  Knorre,  177 
Vorberg,  174 
Voss,  117 


W 

Waelsch,  129,  131 

Walker,  48,  60,  65,  73,  96 

Warfield,  87 

Warren,  168 

Warthin,  60,  97,  120,  127,  135 

Watson,  43 

Welander,  215 

Wender,  90 

White,  42,  72,  222,  252 

Whitney,  61,  73,  97,  99 

Wickes,  184 

WiUiams,  66,  83,  98 

Wilson,  91 

Wolbarst,  181 

Wolfe,  189 

Wolfhugel,  177 


Zedlewski,  114 
Zinsser,  123 


SUBJECT  INDEX. 


Abrasions  not  necessary  for  pene- 
tration of  T.  pallidum,  125,  126 
Accidental  exposure  to  syphilis,  23, 

122,  147 
Adultery  as  the  source  of  infection, 

158,  216 
Advertisements,  the  life  of  quack- 
ery, 243 

used  by  the  city  of  Rochester,  292 
Africa,  incidence  of  syphilis  in,  34 
Age  at  which  venereal  infections 
are  acquired,  30,  47 

in    relation    to    prevalence    of 
syphilis,  58,  77,  81 
Agricultural  laborers  and  syphilis, 

27 
Aneurysm,  19,  27,  209 
Aortitis,  19 
Arabs,  incidence  of  syphilis  among, 

35 
Army,  control  of  syphilis  in  the, 
280 

incidence  among  recruits  for,  76 

soldiers  in  the,  76,  94 

treatment  of  syphilis  in  the,  285 
Arteriosclerosis  and  syphilis,   21 
Asia  minor,   incidence  of  svphilis 

in,  31 
Auburn,  incidence  among  prisoners 

at,  71 
Australia,  incidence  of  syphilis  in, 
40 

law  regarding  venereal  diseases, 
271 

notification  in,  246 
Austrian   army  officers,  syphilitic, 

history  of,  20 

B 

Baltimore,   incidence   of  syphUis 
among  patients  in,   64 


Barber  shops,  control  of,  261 
Barbers,  physical  examination  of, 

262 
Bedford    Reformatory    for    Girls, 
incidence  of  venereal  dis- 
ease in,  47 
poverty  not  cause  of  prosti- 
tution among  the  girls  in, 
215 
Belgium,  incidence  of  syphilis  in, 

38 
Bellevue      hospital,      postmortem 
statistics  from,  54 
Wassermann  tests  in,  55 
Birmingham,  incidence  of  syphilis 

among  patients  in,  64 
Boards  of  health  and  Wassermann 

surveys,  102 
Blood,  infectiousness  of,  116 

inoculation    experiments     with, 

116 
as  source  of  infection  in  phj^si- 

cians,  117,  131 
Treponema  pallidum  in,  116 
Blowpipes  and  extragenital  infec- 
tion, 155,  198 
Boston    City   Hospital,    incidence 
of  syphilis  among  patients  in, 
61 
Marine  Hospital,  incidence  among 
patients  in,  61 
British  army,  incidence  of  syphilis 
in,  41 
Medical  Association  and  notifi- 
cation, 237 
Buccal  infections,  151,  156,  198 
Budapest,  incidence  of  syphilis  in, 
38 


Cadets,  West  Point,  incidence  of 
syphilis  among,  76,  94 


308 


SUBJECT  INDEX 


Calomel  ointment,  failures  to  pro- 
tect, 172 
lanolin  as  a  base  for,  179 
not  invariably  successful,  182 
per  cent,  of  calomel  necessary, 

173 
as  a  prophylactic,   170 
statistics  on  the  use  of,  183 
successful  use  of,  180 
Canada,      incidence     of     syphilis 

among  patients  in,   46 
Casualty    Hospital,     Washington, 
incidence  among  patients  in,  66 
Cerebral  hemorrhage  and  syphilis, 

18,  23 
Cerebrospinal  syphilis,  20 
Chancre,  delayed,  as    a    cause    of 
marital  syphilis,  137 
incubation  period  of,  137 
infectiousness  of.  111 
in  prostitutes  as  a  cause  of  infec-' 

tion,  112 
Treponema  pallidum  in  the.  111 
Chancres,  extragenital,  due  to  cir- 
cumcision, 153 
due  to  cupping,   153 
due  to  kissing,  153,  156 
due  to  minor  operations,  152 
due  to  tattooing,  154 
location  of,  151 
methods  of  transmission,   150 
relative  frequency  of,  148 

in  men  and  women,   149 
genital,    proportion    located    on 
the  prepuce,  163 
Chicago,   control  of  venereal  dis- 
eases in,  297 
incidence     among     patients     in 

hospitals  in,  58 
tuberculosis      sanitarium,     inci- 
dence among  patients  in,   70 
Children,     incidence     of     syphilis 

among  sick,  44,  72,  99 
Chimpanzees,    experimental    work 

on,  169 
China,  incidence  of  syphilis  in,  32, 

33 
Cigarettes  and   syphilis,    31,    155, 

198 
Circumcision  among  Jews,    165 
as  a  cause  of  extragenital  infec- 
tion, 153,  200 
as     a     method     of     preventing 
syphilis,  163 


Circumcision,    control    of,  by  the 

sanitary  officer,  263 
Clinics,     adequacy    of    treatment 
afforded  by,  23,  252 
maintained  by  the  city,  292 
Closet  seats  and  transmission  of 

syphilis,  122 
Colmnbia    Hospital    for    Women, 
Washington,  incidence  in, 
67,  84 
incidence     among     colored 
women  in,  94 
College  men,  incidence  of  syphilis 

among,  77,  82 
CoUes's  law,  118,  146 
Conception,    syphilis    transmitted 

through,  121,  140 
Condom,  origin  of  the,  166 

as  a  preventive  of  venereal  infec- 
tion, 167 
Control  of  barber  shops,  261 
of  syphilis  in  the  army,  280 
outline  of  plan  for,  254 
by  systematic  treatment,   24, 
235 
of  venereal  diseases,  219 
Corlears'  Tuberculosis  Clinic,  inci- 
dence of  syphilis  in,  70 
Criminals,    incidence    of    syphilis 

among,  70,  100 
Cryptogenic  syphilis,  129 
Cure,  difficulty  in  securing,  208 

standard  of,  207,  291 
Cupping  and  extragenital  infection, 
153 


Death-rate  among  syphihtics,  21, 

58 
Delinquents,  juvenile,  incidence  of 
syphUis  among,  74,  75 
negroes,    incidence    of    syphilis 
among,  91,  92 
Denmark,   notification  in,   42 
Derehct  class,  incidence  of  syphilis 

in,  72 
Dermatol  ogical  cases,  incidence  of 

syphilis  among,  54 
Disinfectants,  action  of,  in  fats,  177 
on  the  Treponema   pallidum, 
123 
Dispensaries,   criticism  of  present 
facilities  in,  252 


SUBJECT  INDEX 


309 


Dourine,  analogy  to  syphilis  of, 
127,  213 

Drinking  glasses  and  extragenital 
infection,  122,  198,  262 

Drying  fatal  to  Treponema  palli- 
dum, 122 


E 


Economic  problems  in  relation,  to 

sanitation,  216 
Education    in    the    prevention    of 

venereal  diseases,  217,  247 
Elgin  State  Hospital,  Illinois,  inci- 
dence among  inmates  in,  53,  59 
England,  incidence  of  syphilis  in, 

41 
Enlisted  men  of  the  army,   inci- 
dence of  syphilis  among,  76 
Ethics  of  venereal  prophylaxis,  192 
Etiology  of  syphilis,  109 
Experiments  on  prophylaxis,  170 
Extragenital  chancres,  147 
and  kissing,  152,  156,  198 
and  smokers'  articles,  198 
and  tattooing,  154 
and  vaccination,  148,  151-153, 

156,  199 
and  wet-nurses,  154 
due  to  circumcision,  153 
due  to  cupping,  153 
frequency  of,  148 
location  of,  151 
methods  of  preventing,  197 

of  transmission,  150 
relative  frequency  in  men  and 
women,  149 


Fats,  action  of,  on  disinfectants, 
177 

Fear  of  infection  not  a  deterrent, 
194,  218 

Feeble-minded,  incidence  of  syph- 
ilis among,  73 

Fort  Bayard,  incidence  of  syphilis 
among  tuberculous  soldiers  at, 
69 

France,  incidence  of  syphilis  in,  38 

Freedman's  Hospital,  Washington, 
incidence  among  patients  in,  87 


G 


General  paralysis  as  an  index  of 
frequency  of  syphilis,  42.  {See 
Paresis.) 

Genitotropic  tendency  of  the 
Treponeum  pallidum,  127 

George  Washington  Hospital,  inci- 
dence among  patients  in,  66 

Georgia  State  Sanatorium,  inci- 
dence of  syphilis  among  insane 
in,  89 

Germany,  incidence  of  syphilis  in, 
35 

Girls,  delinquent,  incidence  of 
syphilis  among,  75 

Glasgow,  incidence  of  syphilis 
among  children  of,  44 

Govermnent  Hospital  for  the  In- 
sane, incidence  in,  51,  89 

Gynecological  patients,  incidence 
of  syphilis  among,  43,  66,  67 


Heart  disease  and  syphilis,  19,  21, 

23,  44 
Healthy  men,  incidence  of  syphilis 
among,  76,  100 
women,    incidence    of    syphUis 
among,  83,  96,  101 
Hereditary      syphilis,       incidence 
among  negroes,  92 
in  Australia,  41 
in  France,  39 
in  Germany,  36 
in  San  Francisco,  62 
methods   of   transmission    of, 

142 
results  of,  142 

as  influenced  by  treatment, 
145 
Treponema  pallidum  in,  119 
Hospital     patients,    incidence    of 

syphilis  among,  44,  45,  53,  97 
Hospitals,     general,     the     logical 
place  for  treatment  in,  251 
organization  of  a  department 

of  syphilis  in,  255 
provision    for    treatment    of 

prostitutes  in,  257 
refusal     to     treat     cases     of 
syphilis  in,  249 


310 


SUBJECT  INDEX 


Hospitals,    general,    social   service  I  Locomotor  ataxia  as  an  index  of 


in,  253,  255 
Wassermann  reactions  in, 
255 


102, 


Illinois,  incidence  among  insane 

in,  53 
Indiana  Girls'  School,  incidence  of 
syphilis  among  inmates   of,    75 
Innocent,  syphilis  in  the,  23,  29, 

31,  148 

Interurethral  chancre  as  concealed 

primary  lesion,  130 

evidence    of    penetration     by 

Treponema  pallidum  in,  125 

Insane,  incidence  of  syphilis  among, 

38,  43,  49,  50-53,  63,  96 
Insurance   statistics   on  longevity 
of  syphilitics,  21 


Jews,  incidence  of  syphilis  among, 
58 
relative    prevalence    of    syphilis 
among,  165 
Johns  Hopkins  Hospital,  incidence 
of  syphilis  among  patients  in,  64 
Juvenile  delinquents,  incidence  of 
syphilis  among,  74 


Kenyon  law,  the,  223 
Kissing  as  a  cause  of  extragenital 
syphilis,  23,  153,  156,  198 
party  as  evidence  of  penetration 
of  Treponema  pallidum,  126 


Lanolin    as  a  base    for    calomel 

ointment,  179 
Laws  governing  quackery,  243,  270, 

273 
Leukocytozoon  syphilidis,  109 
Life  expectancy  of  syphilitics,  21 
Locomotor  ataxia,  18,  20,  27,  209  i 


the  incidence  of  syphilis,  42 
London,  venereal  disease  in,  42 
Louisiana,    incidence    of    syphilis" 

among  the  insane  in,  52 


M 

Malays,    relative    prevalence    of 

syphilis  among,  165 
Marital  syphilis,  114,  121 

caused  by  secondary  lesions, 

138 
danger  of,  137 

duration  of  infection  respon- 
sible for,  114,  139, 
frequency  of,  135 
methods  of  transmission,   137 
Marriage,  deferred,  as  a  cause  of 
prostitution,  214 
of  syphilitics,  114,  128,  142,  202 
in  relation  to  infant  mortality, 

146 
rules  for,  205,  206,  209 
Massachusetts,    incidence    among 
insane  in,  50 
law  concerning  sale  of  remedies 
for  venereal  diseases  in,    270 
Wassermann  tests  made  by  State 
Department  of  Health,  61 
Masseurs,     incidence    of    syphilis 

among,  in  New  York,  54 
Mediate  infection,  116,  123,  198 
Medical  inspection  in  Berlin,  226 

in  Paris,  224 
Melbourne,  statistics  from,  41 
Mercurial  preparations  as  prophy- 
lactics, 167 
Mercuric    chloride    as    a    prophy- 
lactic, 175 
Michael  Reese  Hospital,  incidence 
of  syphilis  among  patients  in,  58 
Michigan,    incidence    of     syphilis 
among  insane  in,  52 
patients  in,  59 
Middle      classes,      incidence      of 
syphilis  among  the,  27,    67,    82 
Midwives    and    accidental    infec- 
tions, 117,  201 
control  of,  by  sanitary  officer,  263 
Military    prisoners,    incidence    of 

syphilis  among,  71 
Milk,  infectiousness  of,  117 


SUBJECT  INDEX 


311 


Miners,  incidence  of  syphilis  among, 
in  France,  27,  39 

Minnesota     School      for     Feeble- 
minded, 75 

Minor   operations   as   a   cause   of 
accidental  syphilis,  152 

Missom-i,  State  law  for  regulation 
of  practice  of  medicine  in,  270 

Mohammedans,  relative  prevalence 
of  syphilis  among,  165 

Morality,  lack  of,  among  negroes, 
86 

Mortality  caused  by  syphilis,   18, 
23,  58 
in  hereditary  syphilis,    144 
relative,  among  syphilitics,  22 


N 


Nasal  secretion,  infectiousness  of, 

119 
Naval  accepted  recruits,  incidence 
of  syphilis  among,  80 
prisoners,   incidence   of  syphilis 
among,  71 
Negroes,     incidence     of     syphilis 
among,  85,  87,  89,  91,  94,  101 
morality  among,  lack  of,  86 
Nephritis  caused  by  syphilis,   19, 

23,  118 
New  Jersey  State  Hospital,  inci- 
dence among  patients  in,  63 
New    Orleans,    prevalence    among 

patients  in,  83 
New  York,   incidence  of   syphilis 
among  masseurs   in, 
54 
patients  in,  53 
pedlers,  53 
Wassermann  tests  in  Bellevue 
hospital,  55 
in     Fost-Graduate     Hos- 
pital, 57 
Nicaragua,    incidence    of    syphilis 

in,  34 
Notification,  as  an  aid  to  quackery, 
237,  239,  242 
in  Australia,  40,  246 
a  benefit  to  the  patient,  244,  246 
and  British  Royal  Commission, 

237 
in  Denmark,  42 
a  failure  in  Christiania,  236 


Notification,  false  reporting  a  half- 
way measure  in,  239 
and  lay  opinion,  240,  241 
objections  of  physicians  to,  239 
opinion  of  British  Medical  Asso- 
ciation on,  237 
true  reporting  and  false  report- 
ing, 238 
to  be  secured  by  publicity,  249 
as    a    violation    of    professional 
secrecy,  241,  242 
Nurses  and  syphilis,  117,  201 


Ocular     diseases,     incidence     of 

syphilis  in,  43 
Ohio       Penitentiary,        incidence 

among  prisoners  in,  71 
Orchitis  syphilitica,  120 
Oregon,  incidence  among  insane  in, 

50 
Origin  of  venereal  diseases,  213 
Ozena,  incidence  of  syphilis  in,  44 


Paresis,  18,  19,  20,  27,  38,  42 
and  syphilis  d'emblee,  134 
Treponema  pallidum  in,    125 

Pay,  stoppage  of,  for  venereal  dis- 
ease in  the  army,  283 

Peddlers,     incidence     of     syphilis 
among,  in  New  York,  53 

Penetrating  powers  of  the  Trepo- 
nema pallidum,  124 

Pennsylvania   Hospital,    incidence 
among  patients  in,  65 

Peter     Bent     Brigham     Hospital, 
Wassermann  test  in,  60 

Philadelphia,      incidence      among 
patients  in,  65 

Philippines,  syphilis  in  the,  33 

Physicians,     contracting     syphilis 
during  operations,  131 
danger    to,  from    contact    with 

blood,  117 
and  digital  chancres,  152,  154 
and  vaccinal  syphilis,  153,  156, 
200 

Pipes   as  a   cause  of  extragenital 
infection,  31,  155,  198 


312 


SUBJECT  INDEX 


Postgraduate    Hospital     of    New 
York,  Wassermann  tests  in,  57 
Postmortem  statistics,  41,  54,  60 
Poverty  not  the  cause  of  prostitu- 
tion, 215 
in   relation  to  syphilis,  26,    27, 
29 
Pregnancy,      the      incidence      of 
syphilis  in,  as  an  index  of  the 
prevalence  of  syphilis  in  healthy 
females,  45,  55,  56,  61,  83 
Prepuce,  the  proportion  of  chancres 

on  the,  163 
Profeta's  law,  118,  146 
Prevalence  of  syphilis,  age  in  rela- 
tion to,  58 
in  army,  in  enlisted  men,  76, 

94 
in  Boston  hospitals,  60 
in  candidates  for  commission 

in  the  army,  82,  95 
in  Chicago  hospitals,  58 
in  children's  hospitals,  72,  99 
in  criminals,  70,  100 
in  derelict  classes,  72 
in  dermatological  cases,  54 
in  Elgin  State  Hospital,  59 
in  feeble-minded,  36,  73 
in  France,  39,  40 
in  Germany,  37 
in  groups  of  the  population, 

27,  46,  54 
in  gjTiecological  patients,  43, 

66 
in  Jews,  58,  165 
in  healthy  individuals,  76,  83, 

94,  96,  101 
in  Michigan  hospitals,  59 

insane,  52 
in  negroes  in  the  United  States, 
91,  92,  101 
in  the  Canal  Zone,  87,  92 
in  New  Jersey  insane,  63 
in  New  York  insane,  54 
in  patients,  private,  64-67,  95, 

98 
in  Philadelphia  hospitals,  65 
in  pregnant  women,  39,  45,  55 

61,  83,  95 
in  prisoners,  71,  100 
in  recruits  for  the  army,  76,  94 
■  for  the  navy,  80 
for     the     police     force     of 
Washington,  81,  95 


Prevalence  of  syphilis,  relative,  in 
negroes  and  whites,  64,  68 

in  Richmond  hospitals,   64 

in  San  Francisco  hospitals,  61 

summary  of  results  concern- 
ing, 96 

in  trades,  special,  27,  39,  54 

in  tuberculous,  68,  99 

in  Washington  hospitals,  66 
Prophylaxis,  calomel  ointment,  con- 
clusions as  to  efficiency  of,  191 
discipline  necessary  to  enforce, 

191 
efficiency  of  salves  in,  178 
ethics  of,  192 

expediency  of  introducing,  196 
experimental  work  on,   170 
failures  with,  172 
fear  of  infection  not  a  deterrent, 

194,  195 
human  experiment  to  determine 

efficiency  of,  171 
lanolin  as  a  base  for  salves,  179 
mercuric  chloride,  efficiency  of, 

175 
method  of  applying  prophylactic 

treatment,  192,  282 
percentage  of  calomel  required 

in,  173 
relative    efficiency    of    calomel 

ointment   and   mercuric  chlo- 
ride in,  176 
results   obtained   in    the    army, 
187,  189 

in  the  navy,  186 
soap  as  a  prophylactic,  192 
statistics  on  the  use  of,   183 
status  of,  prior  to  Metchnikoff, 

167 
success  of,  possible  in  civil  life, 

197 
successful  results  with,  180 
Prostitutes,  chancre  in,  as  a  source 

of  infection,  112 
incidence  of  syphilis  among,  44, 

47,  48,  96 
medical  inspection  of,  in  Berlin, 
226 
in  Paris,  224 
previous  occupation  of,  215 
secondary  lesions  in,  as  a  source 

of  infection,  113 
source  of  venereal  infection,  30, 

47,  157 


SUBJECT  INDEX 


313 


Prostitutes,  systematic  treatment 
of,  256 

treatment  in  corrective  institu- 
tions, 259 
Prostitution,   cause  of,  213-216 

demand  for,  221 

possible  methods  of  control  of, 
220 

regulation  of,   224 

relation  of  sanitary  officer  to,  219 

sociological  reform  of,  214 

source  of  syphilis,  157,  216 

supported  by  the  unmarried,  215 

suppression  of,  221,  235 
Publicity  concerning  venereal  in- 
fections, 247 

necessary  to  secure  notification, 
249 


Quacks  in  relation  to  notification 
and  systematic  treatment,  242 

Quackery,  laws  against,  243,  270 
maintained  by  advertising,  243 

Questionnaires  in  regard  to  sexual 
life  of  students,  30 


R 


Razors  and  transmission  of  extra- 
genital syphilis,  122,  156,  261 
Recruits  for  the  army,  incidence 
among,  76,  94 
for  the  navy,  incidence  among,  80 
for  the  police  force  of  Washing- 
ton, incidence  among,  81,  95 
Register  syphilitic,  the,  as  a  means 
for  securing    continuous    treat- 
ment. 289 
Regulation,  clandestines  not  con- 
trolled by,  231 
cost  of  an  efficient  system  exces- 
sive, 234 
criticisms  of,  224 
faults  inherent  in  the  system,  230 
infected  women  not  sufficiently 

treated  by,  229 
males  not  included  in,  233 
minors  are  not  brought  under 

control,  231 
of    practice    of    medicine    and 
surgery,  270 


Regulation,  the  State  a  partner  in 

vice,  233 
Reporting  syphilis  in  New  York, 

17,  240 
Richmond,    incidence    of    syphilis 

among  patients  in,   64 
Rochester,  methods  used  in,  to  con- 
trol syphilis,  292 
Royal  Commission,  the  conclusion 
as  to  incidence  of  syphilis 
in  England,  42 
incidence  in  certain  groups,  26 
opinion    concerning    notifica- 
tion, 237 
special  hospitals  for  venereal 
diseases,  251 
Russia,  incidence  of  syphilis  in,  29 


Saliva,  infectiousness  of,  119,  155 
Salvarsan,  abrogation  of  patent  on, 
260 

cost  of,  259 

importance  in  systematic  treat- 
ment, 236,  251,  259 

instructions  for  use  of,  285  ' 
Sanitary  officers,  their  relation  to 

prostitution,  219,  223 
Sanitation,     dependence     of,     on 

economic  conditions,  216 
San    Francisco,    incidence    among 

patients  in,  61 
Scotland,  incidence  of  syphilis  in,  43 
Secondary  lesions,  duration  of,  112 
infectivity,  139 
marital  syphilis  due  to,  138 
in  prostitutes,  113 
Treponema  pallidum   in,    112 
Serbia,  incidence  of  syphilis  in,  31 
Sex  education,  217,  218 
Sick,  incidence  of  syphilis  among 

the,  97 
Skilled     laborers,      incidence     of 

syphilis  among,  27,  54 
Soap  as  a  prophylactic,  192 
Soda  fountains  a  possible  source  of 

infection,  262 
Solicitation,  arrests  for,  inadequate 

to  control,  258 
Sonoma   State   Home,    California, 

incidence  of  syphilis  among  in- 
mates in,  76 


314 


SUBJECT  INDEX 


Sources  of  infection,  110 
Spermatic  fluid,  inoculation  experi- 
ments with,  120 
source  of  infection,  121,  140 
Treponema  pallidum  in   the, 
120 
Spinal  fluid,  Treponema  pallidum 

in,  119 
Spirocheta  pallida,  109 
Sponges    in    the    transmission    of 

syphilis,  123 
Sputum,  infectiousness  of,  118 
Standard  of  cure,  207 
Statistics  on  use  of  calomel  oint- 
ment, 183 
St.  Luke's  Hospital,  San  Francisco, 
incidence     of     syphilis     among 
patients  in,  62 
Stillbirths,  18,  143 
Students,  Russian,  sexual  life  of,  30 
Sumatra,  incidence  of  syphilis  in,  33 
Suppression  of  prostitution,   221 
Sweat,   infectiousness  of,    118 
Sweden,   incidence   among  prosti- 
tutes in,  49 
Syphilis  and  marriage,  202,  209 
control  of,  254 
d'emblee,  128 

by  conception,  140 
as  origin  of  infection  in  some 
cases   of  paresis   and  loco- 
motor ataxia,  134 
more  common  than  supposed, 
134 
hereditaria  tarda,  143 
insontium,  135,  261 
pravorum,  157 
sine  coitu,  147 
Syphilitic  register,  289 


Tabulation  of  Wassermann  sur- 
veys, 94 
Tattooing  in  relation  to  syphilitic 

infection,  154,  200,  263 
Tertiary  lesions,  infectiousness  of, 
114 
inoculation  experiments  from, 

115 
Treponema  pallidum  in,    115 
Testicles,     syphilitic    lesions    and 
Treponema  pallidum  in,    120 


Textile      workers,      incidence     of 

syphilis  in,  27 
Toilet  articles  in  the  transmission 

of  syphilis,   122,  155 
Towels    in    the    transmission    of 

syphilis,  123 
Trades,  incidence  of  syphilis  among 

special,  27,  39,  54 
Treatment,    systematic,    as     con- 
trasted with  treatment  by 
individuals,  235 
applied  to  pi'ostitutes,  256 
arrest    and    confinement    for 

refusal  of,  257 
present    facilities   inadequate, 

23,  249 
refusal  by  general  hospitals,  249 
Treponema  pallidum  as  the  cause 
of  syplulis,  109 
detection    of,    in    lesions    at 

necropsy,  60 
discovery  of,  169 
disinfectants  in  relation  to,  123 
drying  fatal  to  the,    122 
genitotropic  tendency  of  the, 

127 
in  the  blood,  116 
in  the  brain,  125 
in  the  chancre.  111 
in   congenital   syphilis,    119 
in  secondary  lesions,  112 
in  spermatic  fluid,  120 
in  tertiary  lesions,  115 
in  the  testicles,  120,  127 
in  urine,  118 
length    of    time    it    remains 

localized,  171 
penetrating  powers  of  the,  124 
viability  of  the,  121 
Tropics,    incidence   of   syphilis   in 

the,  32 
Tuberculosis  and  syphilis,  18,  21, 

68,  99 
Tunis,  incidence  of  syphilis  in,  34 


University  of  California  Hospital, 
incidence  of  syphilis  among 
patients  of,  61 
Hospital,  Philadelphia,  incidence 
of  syphilis  among  patients  in, 
65 


SUBJECT  INDEX 


315 


Upper  classes,  incidence  of  syphilis 

in  the,  27 
Urine,  infectiousness  of,  118 

Treponema  pallidum  in,  118 


Vaccination    and    syphilis,    148, 
152,  153,  156,  199 
control  by  sanitary  officers,  263 
Venereal  diseases,  among   girls  in 

the   Bedford    Reformatory, 

47 
among  prostitutes,  30,  47,  157 
Australian     law     concerning, 

246,  271 
city  clinics  for,   253 
control  of,  219,  235,  271,  297 
education,   power  of,  to  pre- 
vent, 217 
fear  of,  218 
hospital     facilities     necessary 

for,  250 
inefficiency  of  present  clinics 

for,  23,  252 
laws  to  prohibit  quackery  in, 

270 
moral  aspect  of,  220 
not  a  pimishmenfc,  193 
origin  of,  213 
proportion  of  yoimg  men  who 

acquire,  46 
publicity  desirable  concerning 

the  prevalence  of,  248 


Venereal  diseases,  special  hospitals 
for,  251 
stoppage   of    pay  for,  in    the 
•      army,  283 
prophylaxis.     {See  Prophylaxis.) 


W 

Washington    Asylum,    incidence 
of  syphilis   among  patients  in, 
66,  93 
Wassermann-fast  cases,  209 

reaction  as  an  index  of  the  inci- 
dence of  syphilis,  41,  45,  95 
by  city  laboratories,  208,  258 
in  hospitals,  102,  225 
technic  of  the,  265 
surveys,  28,  102 

and  syphilis  d'emblee,   135 
tabulation    of    those    by    the 
writer,  94 
Weak-minded,    the    incidence    of 

syphilis  among  the,  36,  73 
Wet-nurses,    in   relation    to    acci- 
dental infection  among,  118,  152, 
154,  201 
Women,      incidence      of     syphilis 
among,  67,  85 


Young  men,   proportion   of,   who 
acquire  venereal  diseases,   46 


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